197606257-8-26-2021-29-AS-KHEN-C6EVDH-20210831162045

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197606257
Report Date: 08/26/2021
Date Signed: 08/26/2021 09:41:40 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, 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
09/08/2020 and conducted by Evaluator Emily Peraldi

COMPLAINT CONTROL NUMBER: 29-AS-20200908142229

FACILITY NAME:	EASTER SEALS SOUTHERN CALIFORNIA PASO ROBLES HOUSE		FACILITY NUMBER:	197606257
ADMINISTRATOR:	MANABAT, JOSEPHINE		FACILITY TYPE:	735
ADDRESS:	7306 PASO ROBLES AVE		TELEPHONE:	(818) 609-8227
CITY:	VAN NUYS	STATE: CA	ZIP CODE:	91406
CAPACITY:	3	CENSUS: 3	DATE:	08/26/2021
		UNANNOUNCED	TIME BEGAN:	09:10 AM
MET WITH:	Jose Turcios		TIME COMPLETED:	09:50 AM

ALLEGATION(S):

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Resident sustained suspicious fractures due to physical abuse

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Emily Peraldi initiated a subsequent complaint visit to the above facility. The purpose of the visit is to conclude an investigation initiated by LPA Kelly Dulek on 09/09/2020. LPA Peraldi spoke with Administrator Danny Vega Tapia on the telephone and Administrator authorized Jose Turcios to sign the report. Administrator is unavailable for today’s visit. Entrance interview conducted

It was alleged that Resident #1 (R1) sustained suspicious hip/leg and rib cage fractures while at the facility. On 09/09/2020, due to the situation surrounding Coronavirus 2019 (COVID-19) and to implement mitigation measures, LPA Dulek conducted a virtual initial 10-day visit, at which time LPA requested copies of pertinent documentation. Investigator Dennis Seng from Community Care Licensing Division’s Investigation’s Branch (CCLD IB) conducted the remainder of the investigation. On 12/01/2020 and 12/02/2020, IB Investigator Seng conducted interviews with facility staff.

Continued on LIC 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Emily Peraldi
LICENSING EVALUATOR SIGNATURE:	DATE: 08/26/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2021

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-20200908142229

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: EASTER SEALS SOUTHERN CALIFORNIA PASO ROBLES HOUSE	FACILITY NUMBER: 197606257
	VISIT DATE: 08/26/2021

NARRATIVE

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Continued from LIC 9099

On 12/01/2020, Investigator Seng observed and attempted to conduct interviews with facility residents. Additionally, on 12/02/2020 and 12/03/2020, Investigator Seng conducted interviews with other relevant parties, including but not limited to, Regional Center staff and medical professionals. Investigator Seng also reviewed R1’s medical records on 12/03/2020 and Incident Reports that were submitted to the Regional Office on 09/06/2020 and 09/07/2020.

Information gathered revealed R1 has a health history including osteoporosis, edema and unsteady gait. R1 ambulates independently. On 09/06/2020, R1 got up to use the restroom and began to fall. Staff intervened, lowering R1 to the ground. Facility staff called 9-1-1, and paramedics came and took R1 for treatment at the hospital. Although facility staff informed paramedics of the fall, this information was not immediately relayed to hospital staff. During R1’s hospitalization on 09/06/2020, R1 was solely treated for edema and subsequently discharged on the same day. On 09/07/2020, facility staff noticed R1, who is non-verbal, to be in pain and unable to stand. Staff immediately called 9-1-1 and R1 was taken to the hospital, where R1 was diagnosed with a broken femur. Medical professionals interviewed indicated that the injuries R1 sustained are consistent with a fall. Los Angeles Police Department (LAPD) investigated the incident, and also indicated R1’s injuries are consistent with a fall. Based on all information gathered, the Department does not have sufficient evidence to determine physical abuse at this time. Therefore, the above allegation “Resident sustained suspicious fractures” is deemed UNSUBSTANATIED at this time.

Exit interview conducted. No citations issued, and a copy of this report sent to the Administrator via email.

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Emily Peraldi
LICENSING EVALUATOR SIGNATURE:	DATE: 08/26/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2021

LIC9099 (FAS) - (06/04)

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