191200236-5-22-2023-34-CR-LSMH-CVWVFJ-20230922162400

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 191200236
Report Date: 05/19/2023
Date Signed: 05/22/2023 10:30:11 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 300 N. CONTINENTAL BLVD. #290B
EL SEGUNDO, CA 90245

This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/07/2023 and conducted by Evaluator Connie Jones-Steward

COMPLAINT CONTROL NUMBER: 34-CR-20230307153930

FACILITY NAME:	FIVE ACRES		FACILITY NUMBER:	191200236
ADMINISTRATOR:	CRANE, SHANNON		FACILITY TYPE:	733
ADDRESS:			TELEPHONE:
CITY:		STATE:	ZIP CODE:
CAPACITY:	16	CENSUS: 16	DATE:	05/19/2023
		UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Claudia Rice, Division Director		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

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9

1) Client was choked by staff during a restraint

INVESTIGATION FINDINGS:

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Licensing Program Analyst Connie Jones-Steward investigated the above allegation. LPA interviewed Staff 1, Staff 2, Staff 3 and the Director Claudia Rice, Client #1 and the DCFS Emergency Response Worker. LPA made three telephone attempts and one written attempt to contact the Sheriff's Detective who investigated the case. However she did not respond. LPA Jones-Steward also reviewed the the Medical Hub Report, the DCFS Investigative Report and the security footage of the incident. The security video clearly showed Staff #1 lifting C1 of the floor in a violent manner. However the alleged choking could not be seen on screen. Staff #1 admitted to grabbing and lifting C1 but denied choking him. The Medical Hub Report indicated bruising congruent with the allegations that Child #1 was grabbed by Staff #1 but did not substantiate the choking.

Based on the investigation by this LPA it is unsubstantiated that Client #1 was chocked by Staff #1. Unsubstantiated means that the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Lakescia Smith
LICENSING EVALUATOR NAME: Connie Jones-Steward
LICENSING EVALUATOR SIGNATURE:	DATE: 05/19/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 1 of 3

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 300 N. CONTINENTAL BLVD. #290B
EL SEGUNDO, CA 90245

This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/07/2023 and conducted by Evaluator Connie Jones-Steward

COMPLAINT CONTROL NUMBER: 34-CR-20230307153930

FACILITY NAME:	FIVE ACRES		FACILITY NUMBER:	191200236
ADMINISTRATOR:	CRANE, SHANNON		FACILITY TYPE:	733
ADDRESS:	760 WEST MOUNTAIN VIEW STREET		TELEPHONE:	(626) 798-6793
CITY:	ALTADENA	STATE: CA	ZIP CODE:	91001
CAPACITY:	16	CENSUS: 16	DATE:	05/19/2023
		UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Claudia Rice, Division Director		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Emergency Intervention Prohibition
-Client received bruises during a restraint
-Client was handled roughly by staff

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst Connie Jones-Steward investigated the above allegation. LPA interviewed Staff 1, Staff 2, Staff 3 and the Director Claudia Rice, Client #1 and the DCFS Emergency Response Worker. LPA made three telephone attempts and one written attempt to contact the Sheriff's Detective who investigated the case. However she did not respond. LPA Jones-Steward also reviewed the the Medical Hub Report, the DCFS Investigative Report and the security footage of the incident. The security video clearly showed Staff #1 lifting C1 of the floor in a violent manner.The Medical Hub Report indicated bruising congruent with the allegations that Child #1 was grabbed by Staff #1

Based on the evidence collected, the allegations that Staff #1 handled Client #1 roughly and that Client #1 received bruises during a restraint are substantiated. Substantiated means that the “preponderance of the evidence” standard has been met.

Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: Lakescia Smith
LICENSING EVALUATOR NAME: Connie Jones-Steward
LICENSING EVALUATOR SIGNATURE:	DATE: 05/19/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 34-CR-20230307153930

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 300 N. CONTINENTAL BLVD. #290B
EL SEGUNDO, CA 90245

FACILITY NAME: FIVE ACRES	FACILITY NUMBER: 191200236
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/19/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 05/18/2023 Section Cited CCR 87095.1(a)(8)	1 2 3 4 5 6 7	Emergency Intervention Prohibition The following emergency interventions are prohibited: Aversive behavior modification interventions including, but not limited to, spanking and corporal punishment, body shaking, water spray, slapping, pinching,	1 2 3 4 5 6 7	Licensee shall present a corrective action plan to the Dept. The plan shall include but not be limited to how Staff #1, Staff2 and Staff #3 will be disciplined and/or retrained on the proper use of restraints.
	8 9 10 11 12 13 14	ammonia vapors, sensory deprivation and electric shock. The facility violated this requirement when Staff #1 lifted client off the floor and assualted him as part of a prohibited restraint	8 9 10 11 12 13 14
Type A 05/17/2023 Section Cited CCR 80054(c)(1)	1 2 3 4 5 6 7	Penalties Notwithstanding Section 80054(a), an immediate penalty of $150 per day shall be assessed for any of the following: Sickness, injury or death of a client has occurred as a result of the deficiency.	1 2 3 4 5 6 7	Licensee shall pay the civil penalty upon receipt or invoice.
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISORS NAME: Lakescia Smith
LICENSING EVALUATOR NAME: Connie Jones-Steward
LICENSING EVALUATOR SIGNATURE:	DATE: 05/19/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2023

LIC9099 (FAS) - (06/04)

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