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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 216803877
Report Date: 04/30/2021
Date Signed: 04/30/2021 03:25:25 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, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/24/2020 and conducted by Evaluator Carla Fernandes-Goes
PUBLIC
COMPLAINT CONTROL NUMBER: 21-AS-20201224065342
FACILITY NAME:YUMI HOMEFACILITY NUMBER:
216803877
ADMINISTRATOR:PERALTA, HANNAHFACILITY TYPE:
735
ADDRESS:810 EUCALYPTUS AVETELEPHONE:
(415) 260-8243
CITY:NOVATOSTATE: CAZIP CODE:
94947
CAPACITY:4CENSUS: 4DATE:
04/30/2021
UNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Hannah Peralta - Licensee/AdministratorTIME COMPLETED:
03:20 PM
ALLEGATION(S):
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Staff restrained resident.
INVESTIGATION FINDINGS:
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The Department conducted a complaint investigation regarding the allegations listed above. Licensing Program Analysts Fernandes-Goes & Hansen conducted a telephone visit due to COVID-19 unannounced for the purpose of closing the investigation and met with Hannah Peralta – Administrator/Licensee.

On 1/4/2021, LPA Fernandes-Goes acquired documentation; and conducted interviews on 12/21/20; 1/4, 4/8, 4/19, and 4/21/2021. During documentation review on file and complainant, client, client’s POA and staff interviews, LPA learned that facility has a program plan which states that “resident must have behavioral support needs which are beyond what is typically supported in a community facility”. However, it doesn’t indicate that facility will conduct restrains. In addition, Behavior intervention plan for resident R1 dated 8/24/2020 states "provide frequent opportunities throughout the day to
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Carla Fernandes-Goes
LICENSING EVALUATOR SIGNATURE:

DATE: 04/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/30/2021
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 3
Control Number 21-AS-20201224065342
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME: YUMI HOME
FACILITY NUMBER: 216803877
VISIT DATE: 04/30/2021
NARRATIVE
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make choices. Model and prompt simple functional communication... Use first/then instruction. During down time when calm, coping strategies." and there is no mention of restraint. Staff S1 & S2 who conducted the restraint have been adequately trained according to training records. Facility is vendorized by Regional Center as a 113- specialized residential facility. Client was restraint as per all the interviews conducted during this investigation, SOC 341, and incident report submitted to the Department by the facility.

According with complaint allegation "Staff restrained resident.” there were related observations made during visit. Based on LPA observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED.

Appeal of Rights Given.

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided.
SUPERVISOR'S NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Carla Fernandes-Goes
LICENSING EVALUATOR SIGNATURE:

DATE: 04/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/30/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 21-AS-20201224065342
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: YUMI HOME
FACILITY NUMBER: 216803877
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/30/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/14/2021
Section Cited
CCR
85161(b)(2)
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85161(b)(2) Emergency Intervention Documentation & Reporting Requirements:This requirement isn't met as evidenced by: Based on interviews 3 out of 3 staff stataed that client C1 was restraint,
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Facility administrator agrees to submit facility restraint protocol/procedure/polices and Staff training requirements to be updated in the plan of operation to CCLD by 5/14/2021.
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however; facility program plan & Behavior Intervention Plan for client C1 doesn't state facility restraint plan or policy for facility which poses a potential Health, Safety or Personal Rights risk to residents 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.
SUPERVISOR'S NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Carla Fernandes-Goes
LICENSING EVALUATOR SIGNATURE:

DATE: 04/30/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/30/2021
LIC9099 (FAS) - (06/04)
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