197800850-7-15-2024-28-AS-DSIS-D7JNNL-20240726103653

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197800850
Report Date: 07/15/2024
Date Signed: 07/15/2024 02:49:45 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/09/2024 and conducted by Evaluator Bennette Pena

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20240709125725

FACILITY NAME:	PAYNE CARE CENTER		FACILITY NUMBER:	197800850
ADMINISTRATOR:	WILLIAMS, LAVONIA PAYNE		FACILITY TYPE:	735
ADDRESS:	181 E. ARROW HIGHWAY		TELEPHONE:	(909) 506-4428
CITY:	CLAREMONT	STATE: CA	ZIP CODE:	91711
CAPACITY:	4	CENSUS: 4	DATE:	07/15/2024
		UNANNOUNCED	TIME BEGAN:	09:37 AM
MET WITH:	Robyn Fleming - Administrator		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Due to lack of supervision resident eloped from the facility.
Staff did not meet reporting requirements.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced initial complaint visit to investigate the above allegations. Upon arrival LPA met with Jeffrey Jackson, DSP I & II and Romelia Becerra, DSP I & II and explained the purpose of the visit. At around 10am, Administrator Robyn Fleming arrived and assisted LPA with the investigation.

The investigation consisted of the following: LPAs obtained copies of Client & Staff Rosters, Facility House Rules, Elopement Protocol, Sign in/out sheet (May 2024-July 2024), Unusual Incident/Injury Reports (SIRs) from June 2023-July 2024, C1's hospital/ER discharge record, and Irwindale Police Department contact information. LPA also reviewed and obtained copies of Client #1 (C1) files such as: Face sheet, Admission's Agreement, Physician Report (07/10/2023), Preplacement Appraisal, and Personal Rights.

In regards to the allegation: Due to lack of supervision resident eloped from the facility. It is alleged that on 7/08/2024, C1 eloped from the facility due to a lack of supervision and was found by the Police the following day. *****REPORT CONTINUED ON LIC9099-C*****

Unsubstantiated

Estimated Days of Completion:

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Bennette Pena
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 07/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2024

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 28-AS-20240709125725

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: PAYNE CARE CENTER	FACILITY NUMBER: 197800850
	VISIT DATE: 07/15/2024

NARRATIVE

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All (4) staff interviewed stated that C1 is self responsible and goes out to the community independently all the time. S1 denied the allegation and stated that it is C1's rights to leave the facility anytime if he wants to. On the night of 7/08/2024, S4 stated that C1 denied eating the cheese that belong to S4 when asked by S4. At approximately 11:45pm on 7/08/2024, C1 told S4 that he was going out for a walk. S4 stated that C1 appeared to be his normal self when he went for a walk. On the morning of 7/09/2024, facility was notified by the police that C1 was found walking in Irwindale and was taken by the police to the hospital ER to be checked out. It was indicated that no first aid was needed. C1 was discharged the same day and was picked up by the staff. A body check was conducted by the staff and no noted injury on C1. S4 stated that he was not too concerned that C1 went out for a walk because C1 has been walking in and out of this facility independently all the time. S4 stated that he informed the Administrator of the incident when his shift was over. Some staff indicated that C1 has a history of eloping. S1 stated that Regional Center has not provided a report to the facility regarding their investigation of this incident. LPA attempted to call the Regional Center 3x, but no response. (3) out of (4) clients interviewed stated that staff are always around to supervise them. Clients interviewed stated that C1 leaves the facility all the time but they don't know if he comes back or not. LPA reviewed the sign in/out book (May 2024-July 2024) which showed C1 leaving in/out of the facility many times. C1's Physician Report dated 07/10/2023 indicates that C1 is able to leave the facility unassisted. Documentation reviewed and interviews conducted do not corroborate this allegation.

In regards to the allegation: Staff did not meet reporting requirements. It is alleged that the staff failed to report the incident to the regional center regarding C1 going missing from the facility for an extended period of time. S1 denied the allegation and stated that she faxed the unusual incident/injury report (SIR) to Community Care Licensing and the Regional Center on 07/09/2024. The report indicated that at 11:45pm on 07/08/2024, C1 told the night staff that he was going out for a walk. S1 stated that C1 has a history of elopement. The facility and Regional Center collectively developed an elopement protocol due to C1's elopement behavior. The protocol stated that if a client does not come back to the facility within 24 hours, then staff will call 911 and notify the Administrator. S1 stated that because of special circumstances, S1 submitted an incident report on 07/09/2024 to the Regional Center and Community Care Licensing even if it's less than 24 hours since C1 left the facility for a walk. Interviewed clients stated that they do not know anything about reporting and that clients keep to themselves. LPA's review of client files and facility file records revealed that the protocol stated that staff will give time up to 24 hours for the client to return before calling 911 or file a missing person's report. File review showed that staff faxed the incident report to the Regional Center and Community Care Licensing on 07/09/2024 (21:47:42 GMT). Facility also submitted incident reports to Community Care Licensing and Regional Center regarding C1's elopement incidents from June 2023-July 2024. LPA attempted to call the Regional Center 3x but no response. Interviews conducted and documentation reviewed do not corroborate this allegation.

Based on statements and interviews conducted with clients and staff as well as reviewed files and facility file records, there was not enough supportive evidence to concur with the reported allegations. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED.

Exit interview, a copy of this report was provided to Robyn Fleming, Administrator.

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Bennette Pena
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 07/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2024

LIC9099 (FAS) - (06/04)

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