195850090-10-16-2023-29-AS-DPEA-CY3PM5-20231130102547

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 195850090
Report Date: 10/16/2023
Date Signed: 10/16/2023 03:38:03 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/19/2022 and conducted by Evaluator Brian Balisi

COMPLAINT CONTROL NUMBER: 29-AS-20221219100025

FACILITY NAME:	SUNSHINE RESIDENTIAL HOME BALBOA		FACILITY NUMBER:	195850090
ADMINISTRATOR:	JOSE, OYINLOYE AUSTINE		FACILITY TYPE:	735
ADDRESS:	7431 JELLICO AVENUE		TELEPHONE:	(818) 274-1809
CITY:	LAKE BALBOA	STATE: CA	ZIP CODE:	91406
CAPACITY:	4	CENSUS: 4	DATE:	10/16/2023
		UNANNOUNCED	TIME BEGAN:	12:54 PM
MET WITH:	Joseph Jose		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Staff inappropriately restrained resident in care.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Brian Balisi conducted a subsequent complaint visit to deliver final findings for the allegation listed above. During today’s visit, LPA met with Joseph Jose and explained the reason for the visit.

On 12/27/2022, from 10:00 a.m. – 01:00 p.m., LPA initiated an unannounced complaint investigation for the allegation listed above. During the visit, LPA toured the physical plant, interviewed staff and residents, reviewed and obtained pertinent documents relevant to the investigation. On 03/24/2023, from 11:00 a.m. – 04:00 p.m., LPA conducted a subsequent complaint investigation. During the subsequent visit, LPA conducted a tour of the physical plant, interviewed staff, residents, responsible parties, as well as, reviewed and obtained additional documentation pertinent to the investigation. Additionally, on 03/24/2023, LPA also conducted interviews with North Los Angeles Regional Service (NLARC) Coordinator and Behaviorist with Mountain Light Behavioral Services Division. On 10/03/2023, LPA interviewed Administrator of Prime Home Health.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:	DATE: 10/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/16/2023

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

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20221219100025

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: SUNSHINE RESIDENTIAL HOME BALBOA	FACILITY NUMBER: 195850090
	VISIT DATE: 10/16/2023

NARRATIVE

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Continued from 9099

It was reported that staff inappropriately restrained resident in care, as it was alleged that a bed sheet may have been used inappropriately to restrain Client #1 (C1). Interviews conducted and records reviewed reflect that on 12/13/2022, at approx. 7:30 a.m., Staff #1 (S1) and Staff #2 (S2) made multiple attempts to bring C1 to the table in C1’s bedroom to have breakfast. C1 then ran out of their room and into the kitchen where C1 physically confronted Staff #3 (S3), by hitting S3 in their face, their head then C1 proceeded to bite S3 on S3’s shoulder. S1 and S2 immediately intervened and brought C1 to the floor safely to control the situation. S2 placed a padded shoe under C1’s head due to C1 attempting to conduct self-harm by banging their head on the floor. C1 eventually calmed, but as S1 and S2 allowed C1 to slowly get up, C1 charged at S3 and bit S3 on their shoulder. S1 safely brought C1 to the ground and S2 was asked to assist in controlling C1 on the floor. S2 placed a pillow under C1’s head to prevent injury from self-harm by banging their head on the ground and attempted to control C1’s arms, while S1 went to control C1’s legs. C1 was actively flailing their limbs while also attempting to hit C1’s face with their knees. S1 then used a bedsheet to wrap around the top of C1’s knees to control both legs at the same time so C1 will not continue to attempt to self-harm as well as injure staff. S3 observed the situation from a safe distance to ensure the safety of the other clients in care, as well as to monitor the use of the manual restraint on C1. 911 was called and arrived at approx. 8:10 a.m. to assist with C1. Records review of C1’s Individual Support Plan (ISP) indicated that manual restraint should only be used as a last resort in cases where the risk of serious injury is high risk. Interviews conducted with C1’s service coordinator and Behaviorist further revealed that S1, S2 and S3 acted within the crisis intervention guidelines in the approved ISP for C1. Based on information obtained throughout the course of the investigation, the department does not have sufficient evidence to determine staff inappropriately restrained client. Therefore, the above allegation is deemed unsubstantiated at this time.

Exit interview conducted and copy of report provided

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:	DATE: 10/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/16/2023

LIC9099 (FAS) - (06/04)

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