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32 | reported staff 1 (S1) taped C1's mouth shut. C2 reported that S1 dragged C1 out of the bedroom. Client 3 (C3) and C5 both reported that S1 yells at C1. Additionally, agency staff S3 reported an incident where S1 tapped C1's hand lightly. Staff 4 (S4) who is an agency staff reported that S1 raises his voice while talking to C1. C1 and C4 did not report anything concerning.
Interviews Conducted with clients by LPA revealed the following: C2, C3, C4, C4 all observed S1 tape C1's mouth shut on various dates. All 4 clients confirmed S1 raising his voice, losing his temper and shouting/yelling at C1. Clients also confirmed witnessing various abuses to C1 such as S1 pulling and dragging C1 from her bed to the living room as well as hitting client on the cheeks, arm and top of legs. Interviews conducted with 3 one on one staff, administrator and facility staff revealed that all staff have witnessed that S1 would talk to C1 in a loud, annoyed at times angry voice. Various staff also confirmed S1 yelling at C1. S3 confirmed to the LPA an incident where she observed S1 tap C1 on the hand lightly.
From approximately 2:45 pm to 4:15 pm and at 5:38 pm LPA conducted interview with S1. S1 confirmed speaking inappropriately to C4 by calling her a bully. S1 confirmed raising his voice when speaking with C1 however stated it was because C1 cannot hear well. S1 also stated "sometimes she is loud, so I have to raise my voice". According to S1 C1 developed a behavior that he "thought he could help to stop". The behavior irritates a lot of people including other clients. S1 also stated that he made a mistake by taping C1's mouth 2 or 3 times. S1 could not recall dates of the incidents. S1 acknowledged what he did not ok, “it was his mistake and he stopped doing it”. S1 confirmed incident where he hit C1's hand "maybe 1,2 3 at most". S1 remembers hitting her but does not remember when or why. S1 confirmed an incident that "happened long time ago" where he pulled C1 out of her bedroom by her hand because she was not sleeping and disturbing her roommate. S1 also confirmed about a week or 2 before leaving he lightly touched C1 on the cheeks so she would close her mouth, S1 also stated that he tapped the top of C1's legs and maybe the arms and telling her to stop moving them. Prior to ending the call S1 stated that he does not deny anything, however he would like to tell the LPA that the reason he did everything was to "stop the condition with the tongue and leg not because he enjoys it." S1 stated he cares about the clients. At 5:38 pm LPA sent a text message to S1 asking how long ago and how many times he put a sock in C1's mouth. S1 responded that he cannot recall when and at 2 the most. Based on the information obtained the allegations of Staff (S1) hit client, Staff (S1) placed tape on the mouth of a client and Staff (S1) spoke inappropriately to clients are Substantiated.
Exit interview conducted copy of report citations and appeal right emailed to the administrator |
Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Type A
08/25/2021
Section Cited
CCR
80046(a) | 1
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7 | (a) An individual can be prohibited from being employed or allowing an individual in a licensed facility as specified in Health and Safety Code Sections 1558 and 1558.1 (1) Health and Safety Code Section 1558 reads: (2) Engaged in conduct which is inimical to the health, morals, welfare, or safety of either an individual in or receiving services from the | 1
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7 | Licensee/Administrator will submit a written plan notifying the department what steps will be taken to clear this deficiency and prevent it from reoccurring. Licensee/Administrator will notify the department in writing what actions if any were taken against staff when the abuse was reported and now that the allegations are substantiated. |
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14 | facility, or the people of the State of California. This requirement was not met as evidenced by: Information obtained which revealed S1 did not comply with the section cited above by taping physically abusing C1 taping C1's mouth shut speaking inappropriately to C1 and C4 which posed an immediate health and safety & personal rights risk to R1. | 8
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Type A
08/25/2021
Section Cited
CCR
80063(a) | 1
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7 | (a) The licensee, whether an individual or other entity, is accountable for the general supervision of the licensed facility, and for the establishment of policies concerning its operation. This requirement was not met as evidenced by: Based on information obtained during the course of the investigation which revealed | 1
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7 | Licensee/Administrator will submit a written plan notifying the department what steps will be taken to clear this deficiency and prevent it from reoccurring. |
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14 | that the licensee did not comply with the section cited above by not being aware of the actions of her staff and not accountable for the general supervision of clients in care, and ensuring staff are properly trained in their mandated reporting requirements annually which posed an immediate health and safety and personal rights risk to R1. | 8
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Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Type A
09/25/2021
Section Cited
CCR
80072(a)(3) | 1
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7 | (a) each client shall have personal rights which include, but are not limited to, the following: (3) To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, threat, mental abuse, or other actions of a punitive nature,
This requirement was not met as Evidence by: | 1
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7 | Licensee will schedule vendorized training for all facility and agency staff in the following topics
1. Person Rights
2. Assembly Bill 40
3. Reporting Requirement
4. Welfare and Institutions Code 15630
5. W & I Code #15655 Dependent Adult Abuse Training: |
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14 | Based on information obtained during the investigation which revealed that agency and facility staff failed to comply with the section above by not reporting the infliction of unusual punishment infliction of pain, mental abuse of R1 to licensee and all proper parties/agencies which posed an immediate health and safety and personal rights risk to clients incare. | 8
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14 | Verification of scheduled training with the trainers credential will need to be submitted within 24 hours and completed by 9/6/2021.
Licensee/administrator will also submit a written statement that the above training will be provided to newly hired staff and all other staff working at the facility annually |
Type A
08/25/2021
Section Cited
CCR
80064(a)(2)(3) | 1
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7 | (a) The administrator shall have the following qualifications: (2) Knowledge of the requirements for providing the type of care and supervision needed by clients, including ability to communicate with such clients.
(3) Knowledge of and ability to comply with applicable law and regulation.
This requirement was not met as Evidence by: | 1
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7 | Licensee/Administrator will submit a written plan notifying the department what steps will be taken to clear this deficiency and prevent it from reoccurring. Licensee/Administrator will notify the department what actions if any were taken against staff when the abuse was reported and now that the allegations are substantiated. |
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14 | Based on information obtained during the investigation which revealed that S1 who is a certified administrator failed to comply with this section by not demonstrating the knowledge and ability to work in a licensed facility by Engaging in conduct which is inimical to the health, and safety and personal rights of the clients in care | 8
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