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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609674
Report Date: 10/06/2021
Date Signed: 10/06/2021 01:13:32 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
04/15/2021 and conducted by Evaluator Jose Gary Tan
COMPLAINT CONTROL NUMBER: 31-AS-20210415122854
FACILITY NAME:VERBENA CTFACILITY NUMBER:
197609674
ADMINISTRATOR:TINDLE, TRACEYFACILITY TYPE:
735
ADDRESS:37318 VERBENA CTTELEPHONE:
(661) 305-4744
CITY:PALMDALESTATE: CAZIP CODE:
93551
CAPACITY:4CENSUS: 4DATE:
10/06/2021
UNANNOUNCEDTIME BEGAN:
10:50 AM
MET WITH:Tracy Tindle - AdministratorTIME COMPLETED:
01:15 PM
ALLEGATION(S):
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Staff member inappropriately restrained resident causing bruising
Facility did not have sufficient staff to meet residents' needs
Residents' were not adequately supervised
Facility did not follow resident's care plan
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Gary Tan conducted an unannounced subsequent visit to this facility to deliver the findings for the above allegations. LPA met with Tracy Tindle and explained the reason for the visit.

- Staff member inappropriately restrained resident causing bruising.

The concerns were addressed that facility staff used manual restrains on the client #1 (C1) causing bruises and scratches on C1.

To investigate the allegation, on 04/23/2021 at 2:30pm, LPA spoke with the Administrator, who indicated that the facility is a surge home and accepts clients that have been exposed to COVID 19 in temporarily basis. C1 was at the facility between 01/13/2021 until 09/27/2021. Administrator admitted using manual restraints on C1. She indicated that on 01/24/2021, C1 was exhibiting aggressive and combative behavior. C1’s actions were posing danger to C1 and to others. (continued on LIC 9099-C)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE:

DATE: 10/06/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2021
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-20210415122854
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: VERBENA CT
FACILITY NUMBER: 197609674
VISIT DATE: 10/06/2021
NARRATIVE
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(continued from LIC 9099)

To stop C1’s self-injuring and aggressive act, the Administrator apply temporary hold on C1 until C1 calmed down. On 04/23/2021 LPA Margaryan requested C1’s facility file and no records were provided.

On 04/25/2021 at 2:00pm, LPA Margaryan spoke with other witnesses involved in C1’s care and supervision. Interviews revealed that although C1 has aggressive behavior, the use of manual restrains are prohibited to control C1’s behavior. A review of incident report submitted to the Licensing office on 01/26/2021 verified the information received from the Administrator. The information revealed during this investigation verified the allegation. Therefore, the allegation is substantiated at this time.

- Facility did not have sufficient staff to meet clients' needs.

It was alleged that C1 requires one to one supervision and the facility had only 1 staff for 3 clients.

To investigate the allegation, on 04/25/2021 at 2:30pm, LPA spoke with the Administrator. Interviews revealed that the Administrator had knowledge that C1 requires close supervision. However, she was unable to bring additional staff to supervise C1 due to staffing shortage.

On 04/25/2021 at 3:00pm LPA Margaryan requested staffing schedule and the Administrator informed that LPA that she was the only staff at the facility. The information available during this investigation, verifies the allegation. Therefore, the allegation is substantiated at this time.

- Clients' were not adequately supervised.

It was reported that the facility clients were left in the car without staff supervision.

On 04/25/2021 at 2:30pm, LPA spoke with the Administrator and she admitted and verified that she left three (3) clients in the car while she went to get the gas and the food previously ordered for the clients. The information revealed from interviews verifies the allegation. Therefore, the allegation is substantiated at this time. (continued on LIC 9099-C)
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE:

DATE: 10/06/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 31-AS-20210415122854
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: VERBENA CT
FACILITY NUMBER: 197609674
VISIT DATE: 10/06/2021
NARRATIVE
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(continued from LIC 9099-C)

- Facility did not follow client's care plan.

It was alleged that the facility did not provide the required hours in accordance with the home’s service level 4I from 1/13/2021 through 1/27/2021.

During the course of investigation, on 04/21/2021 at 2:30pm, the Administrator confirmed that although she was aware that C1 required 24-hour supervision and facility required to provide such support, they were unable to bring additional staff to supervise C1. Based on the statements provided by the Administrator, the facility did not provide one on one supervision for C1 while C1 during consumer’s surge placement. Therefore, the allegation is substantiated at this time.

Citation issued. Appeal rights discussed and given. Exit interview conducted. Copy of this report issued.
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE:

DATE: 10/06/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 31-AS-20210415122854
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: VERBENA CT
FACILITY NUMBER: 197609674
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/06/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/06/2021
Section Cited
CCR
85065(f)
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Personnal Requirements. The licensee shall ensure that all direct services to clients requiring specialized skills are performed by personnel who are licensed or certified to perform the service.

This requirement is not met as evidenced by:
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Proof of correction was submitted by the administrator to NLARC and CCL. Cleared during visit.
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The Licensee did not ensure to provide qualified staff to assist C1’s behavioral problems. This poses an immediate health and safety risk to clients in care.
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Type A
10/06/2021
Section Cited
CCR
85078(a)
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Responsibility for Providing Care and Supervision - In addition to Section 80078, the following shall apply: (1) The licensee shall provide those services identified in the client's needs and services plan as necessary to meet the client's needs.

This requirement is not met as evidenced by:
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Proof of correction was submitted by the administrator to NLARC and CCL. Cleared during visit.
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The Licensee did not ensure to provide 1:1 care and supervision to C1 as it was noted in C1’s care plan. This poses an immediate health and safety risk to clients in care.

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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: Naira Margaryan
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE:

DATE: 10/06/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 31-AS-20210415122854
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: VERBENA CT
FACILITY NUMBER: 197609674
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/06/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/06/2021
Section Cited
CCR
80072(3)
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Personal Rights; 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, coercion, threat, mental abuse, or other actions of a punitive nature.
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Proof of correction was submitted by the administrator to NLARC and CCL. Cleared during visit.
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This requirement is not met as evidence by: The Licensee did not ensure that C1’s personal rights was protected at the facility. Manual restraints were used to control C1’s behavior. This poses an immediate health, safety risk and personal right violation to clients in care.
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Type B
10/06/2021
Section Cited
CCR
80065(a)
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Personnel Requirements: Facility personnel shall be competent to provide the services necessary to meet individual client needs and shall, at all times, be employed in numbers necessary to meet such needs.

This requirement is not met as evidenced by:
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Proof of correction was submitted by the administrator to NLARC and CCL. Cleared during visit.
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The Licensee did not ensure to provide appropriate quantity of qualified staff to supervise facility clients. This poses a potential health and safety risk to clients in care.
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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: Naira Margaryan
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE:

DATE: 10/06/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 5