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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198601841
Report Date: 04/04/2025
Date Signed: 04/04/2025 02:34:36 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
04/01/2025 and conducted by Evaluator Noemi Galarza
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20250401101011
FACILITY NAME:DEVLIN FACILITYFACILITY NUMBER:
198601841
ADMINISTRATOR:TRANAE GATLINFACILITY TYPE:
735
ADDRESS:20516 DEVLIN AVETELEPHONE:
(562) 278-2127
CITY:LAKEWOODSTATE: CAZIP CODE:
90715
CAPACITY:3CENSUS: 3DATE:
04/04/2025
UNANNOUNCEDTIME BEGAN:
09:27 AM
MET WITH:Anny Hyde, Assistant AdministratorTIME COMPLETED:
02:15 PM
ALLEGATION(S):
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Facility staff locked a client in their bedroom.

INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Galarza conducted an initial 10-day complaint investigation visit regarding the above allegations. LPA discussed the purpose of the visit with Assistant Administrator Ann Hyde.

The investigation consisted of: LPA reviewed records, interviewed former staff (S1 & S2) and staff (S3-S5) and toured the facility. Client are non-verbal and were not interviewed. Relevant complaint documents were reviewed and obtained i.e. incident report [3/26/25], C1's Identification and Emergency Information/ Face Sheet, IPP, Appraisal/Needs and Services Plan, Physician's Report, Bowel Monitoring Chart, Functional Capability Assessment, ISP, Care Notes, Program Design/DSP Responsibilities, S1's Personnel Record/Suspension, client roster, and LIC 500 Personnel Report.
Substantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Noemi Galarza
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/04/2025
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-20250401101011
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: 04/04/2025
NARRATIVE
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Allegation: Facility staff locked a client in their bedroom. It is alleged that NOC shift Direct Support Professional (DSP)/staff (S1) locked client (C1's) bedroom door during the night shift. It is unknown if the door was locked all night or only during early morning. According to information obtained, at approximately 7:06 AM, day shift DSP/staff (S2) went to check on C1 and noticed the door was locked. Client (C1's) bedroom doorknob is a privacy door knob that has a twist lock that works from only one side, commonly used for privacy in bedrooms. The door knob is a non-key knob that may be unlocked with a coin,fingernail, or any other key. Staff (S2) stated they unlocked the door using their fingernail. Based on record review, C1 has profound intellectual disability and does not have the mental capacity to unlock a door. Client (C1) is non-verbal and was not interviewed. In order to observe the C1's mental capacity, LPA asked Administrator to direct C1 into C3's bedroom, which currently has the same doorknob C1's room had at the time of the incident. The lock was placed on the door and C1 was instructed to open the door. The client was unable to unlock or open the door, then the interior doorknob lock was unlocked, and the C1 was asked to open the door. When the interior doorknob was unlocked C1 was able to exit the room by pushing the unlocked doorknob. Staff (S1) denied the allegation and stated they closed C1's door because they had understanding that the client was able to come in and out of their room, and did not know C1 lacks mental capacity to unlock the doorknob. Staff (S1) stated they were a new employee and the date of the incident was the first NOC shift they worked alone. A total of five (5) staff were interviewed. Staff stated that whenever C1 is wet with urine the client opens the bedroom door and comes out and communicates non-verbally with staff, informing staff that they are soiled and/or wet. On March 26, 2025, when S2 unlocked C1's bedroom door they found the client heavily soiled. The findings indicate S1 locked the client's door, and C1 was unable to exit their bedroom.

Based on interviews conducted and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Deficiency is being cited according to Title 22. See LIC 9099D.

Exit interview was conducted with Assistant Administrator Ann Hyde. A copy of the report and appeal rights were provided.
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Noemi Galarza
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/04/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 28-AS-20250401101011
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/04/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/05/2025
Section Cited
CCR
80072(a)(7)
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Personal Rights. Except for children’s residential facilities, each client shall have personal rights which include, but are not limited to, the following: Not to be locked in any room, building, or facility premises by day or night. This requirement was not met evidenced by:
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Administrator agreed to submit a written plan of correction by tomorrow.

Submit proof that all staff were trained in personal rights by 4/9/25.

Client (C1's) doorknob was removed a couple of days later, and replaced with a non-locking doorknob.
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Based on interviews conducted, on 3/26/2025 profound intellectually disabled client (C1's) bedroom door was observed locked when day shift staff started their shift at 7 AM. C1 does not have mental capacity to unlock a door. This posed an immediate health and safety risk to client 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.
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Noemi Galarza
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/04/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/04/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 5
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
04/01/2025 and conducted by Evaluator Noemi Galarza
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20250401101011

FACILITY NAME:DEVLIN FACILITYFACILITY NUMBER:
198601841
ADMINISTRATOR:TRANAE GATLINFACILITY TYPE:
735
ADDRESS:20516 DEVLIN AVETELEPHONE:
(562) 278-2127
CITY:LAKEWOODSTATE: CAZIP CODE:
90715
CAPACITY:3CENSUS: 3DATE:
04/04/2025
UNANNOUNCEDTIME BEGAN:
09:27 AM
MET WITH:Anny Hyde, Assistant AdministratorTIME COMPLETED:
02:15 PM
ALLEGATION(S):
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2
3
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5
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9
Facility staff left client in soiled clothing for an extended amount of time.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Galarza conducted an initial 10-day complaint investigation visit regarding the above allegations. LPA discussed the purpose of the visit with Assistant Administrator Ann Hyde.

The investigation consisted of: LPA reviewed records, interviewed former staff (S1 & S2) and staff (S3-S5), toured the facility, and obtained relevant complaint documents i.e.1 incident reports [3/26/25], C1's Identification and Emergency Information/ Face Sheet, IPP, Appraisal/Needs and Services Plan, Physician's Report, Bowel Monitoring Chart, Functional Capability Assessment, ISP, Care Notes, Program Design/DSP Responsibilities, S1's Personnel Record/Suspension, client roster, and LIC 500 Personnel Report.
Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Noemi Galarza
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/04/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 28-AS-20250401101011
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: 04/04/2025
NARRATIVE
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Allegation: Facility staff left client in soiled clothing for an extended amount of time. The complaint alleges that on March 26, 2025, when day shift staff begun their shift there was a strong smell of feces outside client (C1's) bedroom door. Staff (S2) unlocked C1's door and found the client on the bed with feces on their back, clothing, and bedding. A total of five (5) staff were interviewed. Per staff interviews, C1's comforter had to be hosed down prior to being placed in the washer, and feces were observed in C1's pants, underwear, shirt, and body. Staff (S1) denied the allegation. Staff (S1) stated that C1 got up between 5:00 AM - 5:30 AM, and they observed that C1 had loose stool diarrhea. Therefore, C1 was showered. The shower was completed at approximately 5:45 AM. Staff (S1) stated they left the client in their room to relax, while S1 assisted other clients and cooked breakfast. According to S1, at approximately 6:30 AM, they checked on C1, and the client was not soiled at that time. Per staff interviews, at approximately 7:06 AM, C1 was found heavily soiled with loose stool/diarrhea on the client's body, bedding, and clothing. The facility only has one (1) NOC shift DSP staff. The other four (4) staff interviewed did not know how long the client was soiled, but stated that they typically do hourly checks on clients. Since, no other staff aside from S1 worked the NOC shift and C1 had loose stool/diarrhea earlier that morning, there is insufficient evidence to prove incontinence care negligence.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegations is Unsubstantiated.

An exit interview was conducted and a copy of this report was discussed and provided to Assistant Administrator Ann Hyde.
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Noemi Galarza
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/04/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5