216804095-1-17-2024-21-AS-VBEI-CZMTZK-20240119141028

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 216804095
Report Date: 01/17/2024
Date Signed: 01/17/2024 12:22:28 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/18/2023 and conducted by Evaluator Caitlynn Felias

COMPLAINT CONTROL NUMBER: 21-AS-20231018122213

FACILITY NAME:	PROGRESS FOUNDATION - GRAND AVENUE		FACILITY NUMBER:	216804095
ADMINISTRATOR:	HERNANDEZ, ELIZABETH		FACILITY TYPE:	772
ADDRESS:	920 GRAND AVENUE		TELEPHONE:	(707) 257-9704
CITY:	SAN RAFAEL	STATE: CA	ZIP CODE:	94901
CAPACITY:	16	CENSUS: 14	DATE:	01/17/2024
		UNANNOUNCED	TIME BEGAN:	12:00 PM
MET WITH:	Program Director, Riley Reck		TIME COMPLETED:	12:30 PM

ALLEGATION(S):

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Staff did not adequately supervise residents resulting in resident being physically assaulted by other resident while in care.

INVESTIGATION FINDINGS:

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At approximately 12:00PM, Licensing Program Analyst (LPA) Felias arrived unannounced to continue a Complaint Investigation regarding the above allegation and met with Program Director, Riley Reck.

During the course of the Investigation, LPA requested and reviewed documents and conducted interviews. There is an allegation that Staff did not adequately supervise residents resulting in a resident being physically assaulted by other resident while in care. Reporting Party states that Client 1 (C1) punched Client 2 (C2) in the chest during lunch. Information provided to the LPA also stated that C2 did not seek medical treatment. Review of Client 1 (C1’s) Intake Assessment states that they have a history of verbal aggression and physical aggression if provoked. Review of C1’s Physician’s Report and Care Plan did not state that they required one on one supervision. Review of facility documentation dated 10/20/2023 stated that on 10/12/2023, C1 experienced increases in agitation and aggression. C1 and Facility staff contacted the police multiple times so C1 could be assessed by the Crisis Stabilization Unit.
Continued on LIC9099

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:	DATE: 01/17/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/17/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 21-AS-20231018122213

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: PROGRESS FOUNDATION - GRAND AVENUE	FACILITY NUMBER: 216804095
	VISIT DATE: 01/17/2024

NARRATIVE

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Continued from LIC9099

It was determined that C1 did not meet the criteria to be admitted for evaluation. After emergency personnel left the facility, C1 had another increase in agitation and aggression and hit C2 in the chest with a closed fist. Facility staff separated the two clients and C1 was transported to the Crisis Stabilization Unit. Review of C1’s file indicated that C1 was to utilize coping mechanisms if they were feeling angry or dealing with frustration and stress. Staff interviews conducted stated that the level of supervision for clients depends on the support clients need and is determined by hospital assessment and by the facility’s intake assessment upon admittance to the program. Review of Facility’s Plan of Operation states the following: “at least one staff member shall be present at any time there are clients at the facility. A greater number of staff shall be present during times when there are greater numbers of clients in programmed activities… staff/client ratio shall be at least one full-time equivalent direct-service staff for each 2.5 clients served.” The plan of operation also states, “a minimum of two staff counselors will always be on duty and often three or more staff members will be present during the day and evenings when there are more activities and case management services offered and provided." Review of Facility's Time Sheets indicated that there were two staff members on-site during the incident.

Based on record review and interviews conducted, the LPA is unable to determine if a Title 22 Regulation Violation has occurred. Therefore, this allegation is Unsubstantiated.

A finding that the complaint is Unsubstantiated means that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur.

No Deficiencies Cited during visit.

Exit interview conducted. Copy of report discussed and provided to Program Director. Signature on form confirms receipt of documents.

SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:	DATE: 01/17/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/17/2024

LIC9099 (FAS) - (06/04)

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