197600716-4-25-2022-31-AS-ADUA-CDTU6B-20220425151804

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197600716
Report Date: 04/25/2022
Date Signed: 04/25/2022 03:19:02 PM

Document Has Been Signed on 04/25/2022 03:19 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

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

FACILITY NAME:	VISTAS HOME		FACILITY NUMBER:	197600716
ADMINISTRATOR:	JASSO,CARLOS		FACILITY TYPE:	735
ADDRESS:	16778 OTSEGO ST.		TELEPHONE:	(818) 784-1680
CITY:	ENCINO	STATE: CA	ZIP CODE:	91436
CAPACITY: 4		CENSUS: 4	DATE:	04/25/2022
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	01:15 PM
MET WITH:	Carlos Jasso		TIME COMPLETED:	03:30 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Abeye Duguma conducted unannounced case management visit to the facility. At 1:15pm LPA met with the administrator Carlos Jasso, explained the purpose of this visit and conducted a physical plant tour. On 03/23/2022, Community Care Licensing Office received an incident report informing that the facility's client #1 (C1) had a verbal and physical altercation with client #2 (C2) and the facility’s Administrator. The Administrator was assisting C1 with organizing C1’s clothes and C1 suddenly became agitated and yelled “no”! C1 then made a fist toward the Administrator and ran out of the bedroom. The Administrator immediately followed C1 to defuse the situation and as C1 was entering the kitchen area, C1 hit C2 in the mid-section as he stormed past. C1 continued to the office area and sat at the Administrator’s desk and began pounding the table, spitting on the Administrator and throwing his head back. C1 later threw himself to the floor and continued throwing his head back and, to prevent self-injury, the Administrator placed his body in a way that allowed C1 to make contact with the Administrator’s shoulder as opposed to the wall and/or floor. On 04/06/2022, Community Care Licensing Office received an incident report informing that the facility client #1 (C1) had a verbal and physical altercation with client #3 (C3). C1, without provocation, hit C3 in the face (right cheek) with a closed fist. C3 became very upset and yelled at C1. The Administrator immediately intervened, C1 retreated to the bedroom and repeatedly apologized. The Administrator questioned why the altercation took place, but C1 could not offer a response. (CONT. on LIC809)

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Abeye Duguma
LICENSING EVALUATOR SIGNATURE:	DATE: 04/25/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2022

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

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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

FACILITY NAME: VISTAS HOME	FACILITY NUMBER: 197600716
	VISIT DATE: 04/25/2022

NARRATIVE

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On 04/08/2022, Community Care Licensing Office received an incident report informing that the facility's client #1 (C1) had a verbal and physical altercation with client #4 (C4). At breakfast time C4 was walking from the dining room to have breakfast and it was at that moment that C1 walked towards C4 and allegedly bumped C4 on purpose causing C4 to lose balance and almost fell. C4 used the kitchen island and was able to regain balance. In response to the alleged bump, C4 yelled at C1, “Why did you do that”? The Administrator immediately intervened and C4 asked to keep C1 away as C4 was afraid of a repeat incident. C1 retreated to the bedroom. The Administrator asked why C1 did that but could not offer a response and apologized.

On 04/21/2022, Community Care Licensing Office received an incident report informing that the facility client #1 (C1) had a verbal and physical altercation with client #4 (C4). It was alleged by C4 that C1 punched C4 in the face. The Administrator checked C4 for any marks or bruises, but none were visible. C4 stated that they were okay, but to keep C1 away as C4 was afraid of a repeat incident. The Administrator checked on C1 and ask if C1 was angry, but C1 replied “no”. The Administrator asked if C1 hit C4 in the face and C1 replied, “Yes” while placing a fist to C1’s own face. The Administrator asked why C1 did that but could not offer a response and apologized.

On 04/23/2022, Community Care Licensing Office received an incident report informing that the facility's client #1 (C1) had a verbal and physical altercation with client #2 (C2). C1 walked out of his bedroom, walked up to C2 in the kitchen near the counter and unprovoked kicked C2 on the foot and punched C2 on the forearm. Staff #1 (S1) intervened and C1 immediately after retreated to the bedroom. When S1 asked C1 if they were upset, C1 replied, “I’m sorry for what happened.'

During this visit at 1:45pm LPA spoke with the Administrator. Interviews revealed that staff were present during four out of five of the incidents and intervened to de-escalate. During the occasion where there were not any witnesses, the staff overheard the commotion and rush to intervene. At the time of this visit at 2:30pm LPA inspected the facility, specifically the area where the incidents took place. In addition, at 3:00pm LPA requested facility records. LPA will return at later time to complete the case management visit regarding the verbal and physical altercations between C1 and C2, C1 and C3 and C1 and C4.

Exit interview was conducted and a copy of report was issued.

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Abeye Duguma
LICENSING EVALUATOR SIGNATURE:	DATE: 04/25/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2022

LIC809 (FAS) - (06/04)

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