198600706-4-12-2022-28-AS-MVAO-CEJT7P-20220518142901

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198600706
Report Date: 04/12/2022
Date Signed: 04/12/2022 04:15:28 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, 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
07/28/2021 and conducted by Evaluator Alma Gonzalez

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20210728130119

FACILITY NAME:	CATHERINE'S HOMES, INC. (FLOWER ST)		FACILITY NUMBER:	198600706
ADMINISTRATOR:	MICHAEL SAN DIEGO		FACILITY TYPE:	735
ADDRESS:	9130 FLOWER STREET		TELEPHONE:	(562) 263-9866
CITY:	BELLFLOWER	STATE: CA	ZIP CODE:	90706
CAPACITY:	5	CENSUS: 3	DATE:	04/12/2022
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Michael San Diego		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

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Resident Eloped from Facility

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Alma Gonzalez conducted an unannounced complaint visit to gather information pertaining to the above-mentioned allegation. LPA met with Administrator Michael San Diego and explained the reason for the visit.

The investigation consisted of: LPA conducted interviews with Administrator Michael San Diego, Administrator Mellanie Aikman, Direct Support Staff (DSP) Robert John (RJ) Villasenor. LPA attempted to interview Clients 1-3 (C1-3). LPA obtained copies of Staff and Client Rosters. LPA reviewed C1's facility file and collected copies of the following documents: Behavior Assessment dated 6/28/21, Individual Program Plan (IPP) dated 2/11/21, Unusual Incident/ Injury Report LIC624 dated 6/30/21, List of notes regarding C1 from meeting conducted with C1's FM before client placement dated 5/17/21 and Physician's Report for Community Care

(See LIC9099C for continuation)

Substantiated

Estimated Days of Completion:

NAME OF LICENSING PROGRAM MANAGER: Stefanie Coronel
NAME OF LICENSING PROGRAM ANALYST: Alma Gonzalez
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/12/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2022

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 28-AS-20210728130119

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: CATHERINE'S HOMES, INC. (FLOWER ST)	FACILITY NUMBER: 198600706
	VISIT DATE: 04/12/2022

NARRATIVE

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Facilities LIC602 dated 6/17/21. LPA also conducted a tour of the facility which included client rooms and restrooms and the outside of the facility. LPA observed facility gate locks.

The investigation revealed the following: In regard to the allegation, Resident Eloped from Facility, it is alleged that there is a lack of client supervision at the facility and due to that C1 eloped from the facility and facility staff lied about the incident. Allegedly staff reported that C1 was just down the street when in fact C1 was a few blocks away. Date of elopement is unknown. Interview conducted with Administrator San Diego and DSP RJ Villasenor revealed that C1 did elope from the facility on 6/30/21. Staff stated that they were enough facility on schedule on 6/30/21, as there always is, and that C1 was able to elope when staff were tending to other clients and the other staff on schedule was outside of the facility taking care of some laundry. Administrator San Diego stated that he immediately reported the incident as it happened to all required parties which were C1's FM, Harbor Regional Center and Community Care Licensing Division (CCLD) on 6/30/21 the date of the incident. Administrator also indicated that C1 was a new placement and had tried to elope a number of times during the initial adjustment period after the move in. Interview with DSP Villasenor revealed that when he noticed that C1 was not in their room he immediately alerted the other staff on schedule and they began looking for C1. DSP stated that he went outside to look around the facility surroundings and when he looked down the street he noticed that there was a police car so he immediately ran down the street to see if C1 was there. DSP Villasenor got to the corner store and when he went in the store he saw C1 sitting down eating some chips and the police officers notified him that the store employees called them due to not knowing where C1 lived. C1 was brought back to facility and a body check was conducted and no bruising, scratches or anything of concern were noted. Administrator stated that staff ensured that all facility doors were properly locked and that door alarms were properly working. Administrator stated that he additionally had a bell installed in C1's bedroom door as an additional manual alert just in case the battery operated door alarms happened to not be functioning. C2-4 are all non-verbal clients and C1 is not longer a client of the facility. LPA Gonzalez reviewed C1's Behavior Assessment which states that C1 was able to unlock doors when not constantly supervised. One target behavior noted on Assessment is elopement.

Based on interviews conducted with facility staff and review of documents, the preponderance of evidence standard has been met, therefore the above stated allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 and Chapter 1 are being cited on the attached LIC 9099D.

Exit interview was conducted with Administrator Michael San Diego. A copy of the report and appeal rights were provided to Administrator San Diego.

NAME OF LICENSING PROGRAM MANAGER: Stefanie Coronel
NAME OF LICENSING PROGRAM ANALYST: Alma Gonzalez
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/12/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 5

Control Number 28-AS-20210728130119

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: CATHERINE'S HOMES, INC. (FLOWER ST)	FACILITY NUMBER: 198600706
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/12/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 04/13/2022 Section Cited CCR 80078(a)	1 2 3 4 5 6 7	Responsibility for Providing Care and Supervision. (a) The licensee shall provide care and supervision as necessary to meet the client's needs. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Administrator to submit written Plan of Correction to ensure the facility is meeting Title 22 Regulation. Administrator to submit a faxed or mailed copy of POC by due date.
	8 9 10 11 12 13 14	Interviews conducted with administrator and DSP revealed that C1 did elope from the facility on 6/30/21 and was found at a local convenience store. Staff stated that C1 had attempted to elope from the facility several times before 6/30/21, which poses an immediate risk to clients 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.

NAME OF LICENSING PROGRAM MANAGER: Stefanie Coronel
NAME OF LICENSING PROGRAM ANALYST: Alma Gonzalez
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/12/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2022

LIC9099 (FAS) - (06/04)

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