198601841-2-7-2024-28-AS-RORN-D2PNMY-20240222093555

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198601841
Report Date: 02/07/2024
Date Signed: 02/07/2024 12:08:26 PM

Unsubstantiated

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
01/31/2024 and conducted by Evaluator Jose Villalobos

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20240131084700

FACILITY NAME:	DEVLIN FACILITY		FACILITY NUMBER:	198601841
ADMINISTRATOR:	TRANAE GATLIN		FACILITY TYPE:	735
ADDRESS:	20516 DEVLIN AVE		TELEPHONE:	(562) 278-2127
CITY:	LAKEWOOD	STATE: CA	ZIP CODE:	90715
CAPACITY:	3	CENSUS: 3	DATE:	02/07/2024
		UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Administrator Ashilee Jackson		TIME COMPLETED:	12:20 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff locked client in their bedroom
Staff are not adequately trained to meet the needs of residents in care

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Jose Villalobos conducted an unannounced complaint investigation visit for the allegation(s) listed above. LPA met with Administrator Ashilee Jackson and the purpose of the visit was discussed.

LPA conducted the following on todays visit: LPA toured the physical plant, Interviewed Staff #1-#2 (S1-S2) , interviewed Clients #1-2 (C1-C2) , interviewed Clipboard Health staff #1-#2 (W1-W2), collected and reviewed medications records for C#1-3 (C1-C3), and collected copies of C1-C3 Facesheet. C3 was not available for interview. The investigation revealed the following:

In regards to the allegation "Staff locked client in their bedroom" it was alleged that C1 was locked in their room by staff. (2) of (2) Staff interviewed denied the allegation. (2) of (2) clients interviewed could not corroborate the allegation.... Continued on LIC 9099-C

Unsubstantiated

Estimated Days of Completion:

NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Jose Villalobos
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 02/07/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/07/2024

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 2

Control Number 28-AS-20240131084700

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: DEVLIN FACILITY	FACILITY NUMBER: 198601841
	VISIT DATE: 02/07/2024

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Interviews with facility staff and staffing agency denied the allegation and stated that clients are not locked in their rooms. LPA did not observe C1 to be locked in their room upon arrival and throughout the visit. LPA did not observe there to be a lock mechanism on the outer side of the door into C1's room. C1 was unable to provide LPA information regarding alleged incident. LPA was not provided proof that C1 was locked in their room by staff. Based on records review, interviews, and observations conducted; although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated.

In regards to the "Staff are not adequately trained to meet the needs of residents in care" it is alleged that staffing agency staff are not trained to provide medications. (2) of (2) Staff interviewed denied the allegation. (2) of (2) Clients interviewed could not corroborate the allegation. Interviews show that the facility receives staffing assistance from Clipboard Health staffing agency. Interviews with facility staff and staffing agency staff show that all staff providing medications to clients are DSP1-2 certified allowing them to assist clients with self administering medication. LPA observed training certifications and clearances from the staffing agency staff showing they are trained to provide care for the clients in the facility. LPA observed facility staff files to also show medication procedures training's. Interviews stated that in service training's for the facility will also include the staffing agency staff. LPA did not observe medication errors for C1-C3 when reviewing their medications and medication records. Based on records review, interviews, and observations conducted; although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated.

Exit Interview conducted and a copy of this report was provided

NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Jose Villalobos
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 02/07/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/07/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 2