197607398-5-7-2024-31-AS-EMIR-D54MPB-20240509094650

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197607398
Report Date: 05/07/2024
Date Signed: 05/07/2024 01:51:16 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 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
02/23/2023 and conducted by Evaluator Evelin Rios

PUBLIC

COMPLAINT CONTROL NUMBER: 31-AS-20230223143106

FACILITY NAME:	VIP ADULT RESIDENTIAL FACILITY		FACILITY NUMBER:	197607398
ADMINISTRATOR:	TEKOA HUEY		FACILITY TYPE:	735
ADDRESS:	37636 RUBY LANE		TELEPHONE:	(661) 533-3986
CITY:	PALMDALE	STATE: CA	ZIP CODE:	93552
CAPACITY:	6	CENSUS: 4	DATE:	05/07/2024
		UNANNOUNCED	TIME BEGAN:	12:30 PM
MET WITH:	Jermarcus Dumas		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

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Facility administrator is falsifying facility staff certificate(s) training.

INVESTIGATION FINDINGS:

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This is report is to amend the LIC9099 report issued 04/29/2024. Additional information was added to clarify the investigation pertaining to allegation mentioned above and based on new information obtained the determination for the above allegation is changed from Unsubstantiated to Substantiated.

On 05/07/2024 Licensing Program Analysts (LPA) Evelin Rios arrived at the facility to conduct an unannounced subsequent complaint visit to obtain additional information. Upon arrival LPA met with administrator, Jermarcus Dumas. At approximately 12:30 p.m. the administrator contacted the supervisor Tasha Kanaley by telephone and LPA explained the purpose of the visit. An entrance interview was conducted. LPA informed Tasha, LPA did not find evidence Crisis Prevention Institute (CPI) training was completed by staff. Tasha revealed she believed the CPI blue cards to be real and that staff had CPI training conducted by the instructor in February of this year. At approximately 12:50 p.m. administrator provided LPA with three (3) randomly selected staff copies of the CPI blue cards expiring 2025. LPA observed copy of the cards to look the same as the cards provided to LPA on 02/28/2023. (Continued to LIC9099-C)

Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE:	DATE: 05/07/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/07/2024

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 31-AS-20230223143106

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: VIP ADULT RESIDENTIAL FACILITY	FACILITY NUMBER: 197607398
	VISIT DATE: 05/07/2024

NARRATIVE

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Allegation: Facility administrator is falsifying facility staff certificate(s) training. It was alleged that the administrator is falsifying Crisis Prevention Institute (CPI), Direct Support Professional training year 1 (DSP1), and Direct Support Professional training year 2 (DSP2) certificate(s). To investigate this allegation, LPA Rios conducted an initial complaint visit on 02/28/2023 and from 12:00 p.m. to 1:45 p.m. LPA interviewed house manager at the time Jermarcus Dumas, staff #1(S1), reviewed records, obtained copies of staff training certificates for DSP1, DSP2 and blue cards for CPI. Interview with house manager and S1 on 02/28/2023 denied the allegation stating they completed their own training. LPA review of training records did not observe copy of certificates to be altered. LPA's review of twelve(12) staff’ records and training certificate on 02/28/2023 for DSP1 and DSP 2 observed training certificates to differ in appearance with how long ago the training was taken compared to training completed in recent years. LPA could not find staff records for name of staff mentioned on complaint. According to administrator on 04/29/2024 staff mentioned to have worked at facility did not always work at this facility but at another facility. LPA Interview with the administrator at the time, Tasha Kanaley, on 04/29/2024, also stated they did not ask staff to send their training certificates in order to alter the certificates and put another staff member's name on the training document. Interviews with Tasha and administrator Jermarcus on today's visit continue to deny the allegation. LPA Rios was unsuccessful with attempts to contact staff mentioned on complaint. LPA made attempts to call the facility’s CPI instructor on 02/28/2023 and 05/06/2024. LPA did not receive a return call at that time. On 05/01/2024 LPA emailed copies twelve (12) staff blue cards to Crisis Prevention Institute for verification. On 05/02/2024 the Certified Instructor Records Specialist (CIRS) for CPI informed LPA the training could not be verified as the names on the cards were not found on CPI’s database as having completed training. On 05/02/2024 Tasha Kanaley provided LPA with the instructor’s full name and verified telephone number. On 05/07/2024 LPA was able to reach the instructor and sent copies of blue cards provided to LPA by facility. CPI instructor informs LPA the signature is theirs, but they did not sign the cards. Furthermore, the CPI instructor on 05/07/2024 and CIRS on 05/02/2024 both stated not verbatim, the blue cards are issued with numbers, which the ones provided do not have and the information on the card such as name and hours are handwritten and not typed as they appear to be on the CPI blue cards provided by the facility.

Based on facilities own copies of CPI documentation provided to LPA on 02/28/2024, the Certified Instructor Records Specialist (CIRS) for CPI and the facility’s instructor both stated not verbatim they believed the CPI blue cards to be forged. The determination for the allegation; facility administrator is falsifying facility staff certificate(s) training is Substantiated.
Deficiency cited (refer to LIC9099-D). Appeals discussed and provided. Copy of report provided.

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE:	DATE: 05/07/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/07/2024

LIC9099 (FAS) - (06/04)

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Control Number 31-AS-20230223143106

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: VIP ADULT RESIDENTIAL FACILITY	FACILITY NUMBER: 197607398
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/07/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 05/31/2024 Section Cited CCR 80012(a)	1 2 3 4 5 6 7	80012(a) No licensee, officer, or employee of a licensee shall make or disseminate any false or misleading statement regarding the facility or any of the services provided by the facility. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Administrator will have vendorized training on Crisis Prevention and provide a sign-in sheet of all staff that attended along with staff certification. Submit to LPA by POC due date.
	8 9 10 11 12 13 14	Based on the information obtained during the course of the investigation the licensee did not comply with the section cited by providing false/misleading statements to the LPA claiming CPI training on file for staff was legitimate but later found not to be, which poses a potential health, safety, or personal rights risk to a person 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: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE:	DATE: 05/07/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/07/2024

LIC9099 (FAS) - (06/04)

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