<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197606708
Report Date: 08/30/2022
Date Signed: 08/30/2022 03:20:05 PM

Substantiated


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., STE. 250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/08/2022 and conducted by Evaluator Shira Stamps
COMPLAINT CONTROL NUMBER: 31-AS-20220308101315
FACILITY NAME:PALMDALE CARE FACILITY 2FACILITY NUMBER:
197606708
ADMINISTRATOR:DON TURNERFACILITY TYPE:
735
ADDRESS:37632 DALZELL STREETTELEPHONE:
(661) 265-7423
CITY:PALMDALESTATE: CAZIP CODE:
93550
CAPACITY:4CENSUS: 4DATE:
08/30/2022
UNANNOUNCEDTIME BEGAN:
02:38 PM
MET WITH:Valree Zepeda, Administrator TIME COMPLETED:
03:25 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff is verbally abusive to resident.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 8/30/22, Licensing Program Analyst (LPA) Shira Stamps conducted a subsequent complaint visit to deliver the findings of the above allegations.

On 3/09/22 LPA Shanahan initiated the complaint investigation, and on 3/17/22 a subsequent visit was conducted. LPAs conducted physical plant tours, collected relevant documents, and interviewed staff and clients. A record review was conducted which included, but not limited to C1’s IPP and Behavior Plan. It is alleged that client #1 (C1) was arguing with staff member #1 (S1) and was pushed into the stove by S1 causing C1 to slip on water resulting in a blister on C1’s elbow.

CONTINUED...
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Shira Stamps
LICENSING EVALUATOR SIGNATURE:

DATE: 08/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2022
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 5
Control Number 31-AS-20220308101315
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., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: PALMDALE CARE FACILITY 2
FACILITY NUMBER: 197606708
VISIT DATE: 08/30/2022
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
26
27
28
29
30
31
32
Allegation: Staff is verbally abusive to resident.

It is alleged that staff is verbally abusive to clients. Interviews with two (2) out four (4) clients indicated that staff pick on clients and start arguments when the staff are having a bad day. The two (2) clients were unable to give specific examples of what staff have said to clients. Interviews with the other two (2) clients indicated staff are not verbally abusive to clients. Interviews with staff indicated that staff raise their voice to clients, but do not yell at the clients. It was indicated by staff interviews that staff have told clients to,” get out of their face” when a client is having a behavior episode, and staff have told clients, “I don’t care if you are having a behavior episode”. Based on interviews staff have spoken to clients in a way that is abusive, therefore the allegation, “Staff is verbally abusive to residents”, is deemed substantiated.

Exit interview conducted, citations issued, and a copy of appeal rights and report delivered to the Administrator.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Shira Stamps
LICENSING EVALUATOR SIGNATURE:

DATE: 08/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 5
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., STE. 250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/08/2022 and conducted by Evaluator Shira Stamps
COMPLAINT CONTROL NUMBER: 31-AS-20220308101315

FACILITY NAME:PALMDALE CARE FACILITY 2FACILITY NUMBER:
197606708
ADMINISTRATOR:DON TURNERFACILITY TYPE:
735
ADDRESS:37632 DALZELL STREETTELEPHONE:
(661) 265-7423
CITY:PALMDALESTATE: CAZIP CODE:
93550
CAPACITY:4CENSUS: 4DATE:
08/30/2022
UNANNOUNCEDTIME BEGAN:
02:38 PM
MET WITH:Valree Zepeda, Administrator TIME COMPLETED:
03:25 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff pushed the resident.
Resident was injured while in care.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 8/30/22, Licensing Program Analyst (LPA) Shira Stamps conducted a subsequent complaint visit to deliver the findings of the above allegations.

On 3/09/22 LPA Shanahan initiated the complaint investigation, and on 3/17/22 a subsequent visit was conducted. LPAs conducted physical plant tours, collected relevant documents, and interviewed staff and clients. A record review was conducted which included, but not limited to C1’s IPP () and Behavior Plan. It is alleged that client #1 (C1) was arguing with staff member #1 (S1) and was pushed into the stove by S1 causing C1 to slip on water resulting in a blister on C1’s elbow.

Allegation: Staff pushed resident.

It was alleged that S1 pushed C1 into the stove. Interviews with (2) out of (4) clients found that staff have never pushed clients. Three (3) out of four (4) clients did not witness the incident. CONTINUED...
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Shira Stamps
LICENSING EVALUATOR SIGNATURE:

DATE: 08/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 31-AS-20220308101315
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., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: PALMDALE CARE FACILITY 2
FACILITY NUMBER: 197606708
VISIT DATE: 08/30/2022
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
26
27
28
29
30
31
32
Staff interviews indicated S1 did not touch or push C1 into the stove. Interviews with staff indicated S1 put their hands up to protect them self from the client and did not push the client. There is a lack of supportive evidence to indicate S1 pushed C1 into the stove. Therefore, the allegation, “Staff pushed resident,” is deemed unsubstantiated at this time.

Allegation: Resident was injured while in care.

It is alleged that S1 caused injury to C1 by pushing C1 into the stove causing C1 to be burned by the stove resulting in a blister on C1’s elbow. Staff interviews indicated that C1 slipped on water that was on the floor causing C1 to slip and fall into the stove resulting in a blister on C1’s elbow. Interviews with (3) out of (4) clients indicated they did not witness the incident and indicated staff have never injured a client. Due to a lack of supportive evidence, C1 was injured in the facility, but it was not determined if S1 was the cause of C1’s injury. Therefore, the allegation, “Resident was injured while in care,” is deemed unsubstantiated.

Exit interview conducted and a copy of appeal rights and report delivered to the Administrator.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Shira Stamps
LICENSING EVALUATOR SIGNATURE:

DATE: 08/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 31-AS-20220308101315
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., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: PALMDALE CARE FACILITY 2
FACILITY NUMBER: 197606708
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/30/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/06/2022
Section Cited
CCR
80072(a)(1)
1
2
3
4
5
6
7
To be accorded dignity in his/her personal relationships with staff and other persons

This requirement is not met as evidenced by:
1
2
3
4
5
6
7
The Administrator states she will provide personal rights training to all staff members, and will provide LPA with training materials and signatures of all staff that have completed the training by the POC due date.
8
9
10
11
12
13
14
Based on interviews, the facility did not ensure that clients’ are afforded dignity in their relationship with staff which poses a potential personal rights risk to client’s in care.
8
9
10
11
12
13
14
1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: Nichelle Gillyard
LICENSING EVALUATOR NAME: Shira Stamps
LICENSING EVALUATOR SIGNATURE:

DATE: 08/30/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 5