306004295-3-15-2022-22-AS-AJLO-CGFVD4-20220718162005

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306004295
Report Date: 03/15/2022
Date Signed: 03/15/2022 11:16:56 AM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/08/2022 and conducted by Evaluator Sean Haddad

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20220308152514

FACILITY NAME:	NELDYS ADULT RESIDENTIAL CARE HOME		FACILITY NUMBER:	306004295
ADMINISTRATOR:	JON NEIL CASTRO		FACILITY TYPE:	735
ADDRESS:	11411 STANFORD AVENUE		TELEPHONE:	(714) 539-5151
CITY:	GARDEN GROVE	STATE: CA	ZIP CODE:	92840
CAPACITY:	6	CENSUS: 5	DATE:	03/15/2022
		UNANNOUNCED	TIME BEGAN:	09:27 AM
MET WITH:	Jon Neil Castro		TIME COMPLETED:	11:30 AM

ALLEGATION(S):

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Client was punched in the face by another client.
Client sustained a black eye while in care.

INVESTIGATION FINDINGS:

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This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad to investigate the above-mentioned complaint allegations. LPA met with Administrator (AD) Jon Neil Castro, discussed the purpose of the inspection, and explained the allegations. During the inspection, LPA inspected the facility, interviewed AD and staff, interviewed 3 clients, conducted a health and safety check on clients, and requested and reviewed resident roster, staff roster, client files, and other pertinent records.

The investigation into the allegations that Client was punched in the face by another client and that Client sustained a black eye while in care revealed the following: It was reported that Client #1 (C1) was punched in the face by another client at the facility and sustained a black eye. On 03/15/2022, LPA interviewed AD and another staff who corroborated that on or around 03/05/2022, there was a fight between C1 and Client #2 (C2) which resulted in C2 punching C1 in the face resulting in a black eye to C1. LPA’s interviews with C1, C2, and a third client corroborated the allegations.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Marina Stanic	TELEPHONE: (714) 703-2851
LICENSING EVALUATOR NAME: Sean Haddad	TELEPHONE: (714) 335-7094
LICENSING EVALUATOR SIGNATURE:	DATE: 03/15/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/15/2022

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 22-AS-20220308152514

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: NELDYS ADULT RESIDENTIAL CARE HOME	FACILITY NUMBER: 306004295
	VISIT DATE: 03/15/2022

NARRATIVE

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All witnesses interviewed stated that C1 and C2 have a history of shouting at each other and fighting. Per AD, the facility’s main measure taken to redirect altercations is to separate C1 and C2 after a fight. In this particular incident, C1 and C2 had begun shouting at each other and were separated by staff. However, C1 and C2 were still angry with each other when they ran into each other in the hallway shortly after. It was this point where C2 punched C1 in the face resulting in a back eye. Thus, the allegations that Client was punched in the face by another client and that Client sustained a black eye while in care are substantiated. During the inspection, AD stated they will train all care staff to provide 1 on 1 supervision to either C1 or C2 after a fight for as long as necessary until the clients calm down or make peace with each other. AD also stated they will continue to pursue additional solutions with the clients’ behavioral specialists and regional center, including relocation of one of the clients if necessary.

During the course of the investigation, Community Care Licensing obtained sufficient evidence to substantiate the allegations mentioned above. The preponderance of evidence standard has been met; therefore, the above allegations are substantiated. See LIC9099D for cited deficiencies per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative.

SUPERVISOR'S NAME: Marina Stanic	TELEPHONE: (714) 703-2851
LICENSING EVALUATOR NAME: Sean Haddad	TELEPHONE: (714) 335-7094
LICENSING EVALUATOR SIGNATURE:	DATE: 03/15/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/15/2022

LIC9099 (FAS) - (06/04)

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Control Number 22-AS-20220308152514

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: NELDYS ADULT RESIDENTIAL CARE HOME	FACILITY NUMBER: 306004295
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/15/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 03/16/2022 Section Cited CCR 80078(a)	1 2 3 4 5 6 7	80078 Responsibility for Providing Care and Supervision (a) The licensee shall provide care and supervision as necessary to meet the client's needs. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Licensee stated they will train all care staff to provide 1 on 1 supervision to either C1 or C2 after a fight for as long as necessary until the clients calm down or make peace with each other by POC due date and submit proof to LPA within 7 days of POC due date.
	8 9 10 11 12 13 14	Based on interviews, the facility did not provide care and supervision as necessary to prevent 2 clients from fighting resulting in a black eye to 1 of the clients, which poses an immediate safety and personal rights risk to persons in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Marina Stanic	TELEPHONE: (714) 703-2851
LICENSING EVALUATOR NAME: Sean Haddad	TELEPHONE: (714) 335-7094
LICENSING EVALUATOR SIGNATURE:	DATE: 03/15/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/15/2022

LIC9099 (FAS) - (06/04)

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