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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198600706
Report Date: 05/13/2022
Date Signed: 05/13/2022 04:12:10 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 DIEGOFACILITY TYPE:
735
ADDRESS:9130 FLOWER STREETTELEPHONE:
(562) 263-9866
CITY:BELLFLOWERSTATE: CAZIP CODE:
90706
CAPACITY:5CENSUS: 4DATE:
05/13/2022
UNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Robert John VillasenorTIME COMPLETED:
03:45 PM
ALLEGATION(S):
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Resident Sustained severe burns while in Care
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Alma Gonzalez conducted a subsequent visit to deliver complaint investigation findings. LPA met with Direct Care Staff Personnel (DSP) Robert John Villasenor and explained the purpose of the visit.

Investigation consisted of the following: During the initial visit conducted on 7/29/21, LPA Gonzalez requested a copy of Staff and Client rosters. LPA and Administrator Michael San Diego conducted a Health and Safety check which included a tour of the entire facility inside and out. Facility consists of four (5) client bedrooms, two (2) staff bedrooms, two (2) client bathrooms, and one (1) staff bathroom, living room, den, kitchen and dining area. LPA measured the water temperatures in all three (3) facility bathrooms and the following temperatures were noted: Staff bathroom which is Bathroom #3 (located in the front of the facility in the



(See LIC 9099C for continuation of report)
Substantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Stefanie Coronel
NAME OF LICENSING PROGRAM ANALYST: Alma Gonzalez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2022
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 4
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: 05/13/2022
NARRATIVE
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middle of two (2) staff bedrooms temperature reading measured 125 degrees F (Administrator also measured the temperature and the reading on his thermometer was 121.6), Bathroom #1 temperature measured 126.5 (Administrator measured 124.4) and Bathroom #2 measured 122 F (Administrator measured 120.4). LPA did not observe any signs of neglect, abuse or other immediate health and safety threats. LPA observed three (3) clients in the facility.

The investigation for this complaint was conducted by Investigator Philippe Ryan Miles.

During the course of this investigation, On 08/24/21, Investigator Miles reviewed a written statement/ administrative Investigation document completed by Staff 1 (S1). On 09/16/21, Mr. Miles conducted interviews with Client 1 (C1), and C1's Family Member (C1 FM). On 09/20/21, Investigator Miles reviewed Providence St. Jude Hospital Medical Records. On 09/30/21, Investigator Miles interviewed S2, and Administrator San Diego. On 10/04/21, Mr. Miles reviewed Orange County Global Medical Center Hospital Medical Records. On 10/05/21, S1 was interviewed in person at the CA Department of Social Services (CDSS) Souther Division, Investigative Branch located in Monterey Park, Ca. On 10/11/21, Mr. Miles interviewed S3. On 10/12/21, Mr. Miles made observations of shower head and tested the water temperature with a reading of 112.4 F and also tested the water temperature of the water dispenser which was 166.6F. Investigator additionally interviewed Administrator San Diego, and S2. On 10/18/21, Mr. Miles conducted a telephone interview with Medical Director of the Orange County Global Medical Center Andrea Dunkelman.

The investigation revealed the following: Regarding allegation of Resident Sustained severe burns while in Care, It is alleged that C1 was admitted to Orange County Global Medical Center with severe second and third degree burns on their face and neck. EMS report indicated 911 was called after staff found C1 with burns when doing rounds, but there was unclear etiology and Administrator was unable to explain what happened. MD documentation indicated that it appeared that C1 may have been doused with a hot scalding substance on their face.

Investigator Miles conducted interviews with facility staff, C1's FM and attempted to interview C1 but client is non-verbal and was not able to communicate the cause of their injuries. The investigation revealed that on 07/23/21, S1 left C1 unattended in the shower room to discard a diaper outside of the facility. When S1 returned, S1 found C1 wet from head to toe. When S1 dried C1 with a towel, C1 screamed while their skin
NAME OF LICENSING PROGRAM MANAGER: Stefanie Coronel
NAME OF LICENSING PROGRAM ANALYST: Alma Gonzalez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 4
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: 05/13/2022
NARRATIVE
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was sticking and peeling onto the towel. S1 contacted Administrator San Diego who transported C1 to Providence St. Jude Medical Center. C1 presented multiple burns on their neck and face. 911 was never notified. C1 was then transferred to Orange County Global Medical Center (Burn Center) and was evaluated by medical staff with "severe" second and third degree burns. Administrator San Diego admitted that S1 failed to provide care and supervision for C1. S1 admitted that they were the only staff on duty who neglected C1 and left C1 unattended in the shower room where the injuries occurred. S1 admitted that they did not provide adequate care and supervision for C1. C1 sustained second and third degree burns located mostly on the right side of their face, scalp, right side of neck and the back of upper torso. Based on observations made by the medical staff, C1 suffered from some sort of scalding substance poured on their face, neck and back. S1 denied pouring a scalding hot liquid or substance on C1 causing the injuries. Based on Dr. Dunkelman's medical opinion, "It seems it is more consistent with someone pouring scalding water or hot liquid based on the information that was provided regarding S1, who found the shower head hanging near the feet with the water spraying directly towards the shower wall, not located above the head; and the shower head not mounted on it's fixture above the head." Investigator Miles also stated that his investigation revealed that the clients are unlikely to cause any harm towards C1 since they need assistance with their Activities of Daily Living (ADL's) and are not capable of manipulating the hot water safety switch on water dispenser. Investigator Miles observed S1 to appear nervous throughout the interview and make inconsistent statements regarding how the incident/ injuries occurred.

Based on interviews conducted and records reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Tittle 22, Division 6 and Chapter 1 are being cited.

Immediate Civil Penalties will be issued today, in the amount of $500.00 due to Resident Sustained severe burns while in Care.

At this time an Enhanced Civil Penalty (ECP) determination is pending in reference to Health and Safety Code 1548(f)(1)(B)(i) and may be assessed at a later date.

Exit interview held. A copy of the LIC9099, LIC9099C, LIC9099D and LIC421M (Civil Penalty Assessment), and Appeal Rights were provided to Direct Care Staff Personnel (DSP) Robert John Villasenor.
NAME OF LICENSING PROGRAM MANAGER: Stefanie Coronel
NAME OF LICENSING PROGRAM ANALYST: Alma Gonzalez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 4
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: 05/13/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/14/2022
Section Cited
CCR
80072(a)(2)
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Personal Rights
(a) Except for children’s residential facilities, each client shall have personal rights which include, but are not limited to, the following:
(2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs.
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Licensee shall develop a written Plan of Correction to ensure compliance with California Code of Regulations Title 22, Section 80072(a)(2). Written POC must be submitted to CCL by the POC due date.
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This requirement was not met as evidenced by:

Interviews conducted with facility staff, review of medical records and interview with doctor revealed that C1 sustained severe second and third degree burns on 07/23/21 when S1 left C1 unattended in the shower to go out of the facility to dispose of a diaper. This poses an immediate hazard to clients in care.
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**Immediate Civil Penalties will be assessed in the amount of $500.00.**
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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.
NAME OF LICENSING PROGRAM MANAGER: Stefanie Coronel
NAME OF LICENSING PROGRAM ANALYST: Alma Gonzalez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/13/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 4