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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306004435
Report Date: 01/12/2023
Date Signed: 01/20/2023 01:46:01 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, 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
12/09/2022 and conducted by Evaluator Andrea Mendivil
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20221209161303
FACILITY NAME:STONYBROOK RESIDENTAL CARE IFACILITY NUMBER:
306004435
ADMINISTRATOR:BRANDON PENALOSAFACILITY TYPE:
735
ADDRESS:9542 STONYBROOK DRIVETELEPHONE:
(657) 208-1902
CITY:ANAHEIMSTATE: CAZIP CODE:
92804
CAPACITY:5CENSUS: 4DATE:
01/12/2023
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:TIME COMPLETED:
03:45 PM
ALLEGATION(S):
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Personal Rights: staff hit resident
INVESTIGATION FINDINGS:
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On this day Licensing Program Analyst (LPA) Andrea Mendivil made an unannounced visit to deliver findings. LPA was greeted and granted entry to the facility by House Manager Gladys Framo and discussed the findings for the allegation above.

The department received a complaint on 12/12/2022 and the department made an intiail visit on 12/14/2022. During the course of the investigation, the Department interviewed staff, clients and witnesses. In addition the department obtained copies of Individual Program Plan dated 08/23/2022. Regarding the allegation facility staff hit a client, the investigation revealed the following:

Based on an interview with a witness it was alleged on 12/09/22 facility staff either hit or open palmed client 1's (C1) forehead after C1 had been screaming all day. Based on interview wiith witness, C1 yells or screams every monrning from 8:30-10 am , but on 12/09/2022 it was all day. CONT on 9099-C dated 01/12/2023
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Andrea Mendivil
LICENSING EVALUATOR SIGNATURE:

DATE: 01/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2023
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 22-AS-20221209161303
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: STONYBROOK RESIDENTAL CARE I
FACILITY NUMBER: 306004435
VISIT DATE: 01/12/2023
NARRATIVE
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Based on interview with facility staff 1 (S1) the Orange County Sheriff performed a wellness check and did not provide names or a card. Interviews with 5 out of 5 staff reported C1's behavior is to scream or yell when they are not getting attention as C1 is nonverbal and cannot communicate with words.

Per IPP dated 08/23/2022 indicates that C1 can become aggressive or have emotional outburst if they believe that others are gaining more attention then they are. Per IPP C1 has repeatedly yelled, screamed, pinched, spit and pulled staff's hair. Based on IPP C1's emotional outbursts can be defined as screaming, yelling that emanates 7 foot distance. Per interview with Administrator Brandon Penalosa, on the day of 12/09/2022 the facility had meetings for other clients which resulted in C1 having emotional outbursts of yelling and screaming.

Interviews with 5 out of 5 staff indicate they do not yell, hit or scream back at C1 and deny all allegations of hitting C1. Based on interviews with 2 out of 5 residents indicated staff does not yell or hit anyone in the home. LPA was unable to interview 3 clients due to 2 client are non verbal and the last client did not wish to be interviewed.

Therefore based on the preponderance of evidence based on observation and interviews the allegation staff hit client is UNSUBSTANTIATED, meaning that although the allegation may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violation occurred. This agency has investigated this complaint.

No deficiencies cited.
An exit interview was conducted and a copy of this report and confidential names list was provided
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Andrea Mendivil
LICENSING EVALUATOR SIGNATURE:

DATE: 01/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2