306004662-9-8-2023-22-AS-AORZ-CVGUE8-20230908153041

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306004662
Report Date: 09/06/2023
Date Signed: 09/08/2023 03:28:20 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 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
06/16/2020 and conducted by Evaluator Jenifer Tirre

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20200616163352

FACILITY NAME:	CATHERINE'S RESIDENTIAL CARE HOME		FACILITY NUMBER:	306004662
ADMINISTRATOR:	MICHAEL SAN DIEGO		FACILITY TYPE:	735
ADDRESS:	700 WEST AVENUE		TELEPHONE:	(714) 879-5139
CITY:	FULLERTON	STATE: CA	ZIP CODE:	92832
CAPACITY:	6	CENSUS: 6	DATE:	09/06/2023
		UNANNOUNCED	TIME BEGAN:	12:25 AM
MET WITH:	Administrator/Licensee Michael San Diego		TIME COMPLETED:	01:20 PM

ALLEGATION(S):

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Facility staff held residents arm over flame on stove
Administrator asked resident not to tell anyone about incident.
Two staff hitting residents.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Jenifer Tirre met with Administrator/ Licensee Michael San Diego to discuss the findings for the above allegations. The investigation consisted of interviews with staff, client, and Regional Center Staff. Investigation also consisted of reviewed documentation such as Police Report, Regional Center of Orange County Individual Program Plan, Special Incident Report, and photos provided. Observations were also made and the time of complaint visits. The investigation revealed the following:

On 6/16/2020 The department received allegations that facility staff held resident’s arm over flame on stove, Administrator asked resident not to tell anyone about incident and two staff hitting residents. Per interviews conducted with staff, two of two staff both confirm that Kitchen stove is never left unattended. Administrator stated they learned of Client 1’s arm the day after incident and that a Regional Center Quality Assurance Coordinator stated “you can ask your client about the matter” regarding burn on client’s arm. Interviews with staff revealed that to their knowledge there is no physical abuse happening at facility. CONTINUED ON 9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Jenifer Tirre
LICENSING EVALUATOR SIGNATURE:	DATE: 09/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2023

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-20200616163352

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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

FACILITY NAME: CATHERINE'S RESIDENTIAL CARE HOME	FACILITY NUMBER: 306004662
	VISIT DATE: 09/06/2023

NARRATIVE

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Administrator stated Staff 1 was helping assist with another client who required additional assistance and wasn’t normally at facility but was present during the day of the incident. Interviews revealed that Staff 1 was suspended pending internal investigation by Licensee. Administrator also confirmed that they did not tell clients not to say anything and replied that they encourage their clients to “say something “ if they have feelings they need to get out. Interviews with staff indicated that Client 1 is expressive about feelings. Interviews with Regional Center staff revealed that two of two staff confirmed that client had walked into kitchen to throw away trash inside trashcan located underneath stove and while reaching to throw away trash, accidentally burned arm on hot pan that was on stove. Quality Assurance Coordinator confirms that Client 1 demonstrated this to them during their visit. Interview with Client 1 confirmed that though hard to understand Client 1 was able to communicate they were not hurt, and their arm was not held over stove.

Based off documentation, investigation revealed the following: Fullerton Police Department Report confirms that Client 1 showed staff 2 posterior view of arm burned. Report revealed that staff 2 questioned staff 1 regarding client’s arm to which Staff 1 indicated that Client went to throw something away in trash and accidentally burned arm on stove. Report also revealed that Officer attempted talking to Client 1 but could only get the words “burn” and “Kitchen”. Officer stated that burn was 3 inches long and only top layer of skin noting that “it did not appear to be as someone held arm on stove top”. Report revealed that “no further action was taken by officer” and report was concluded. Photos provided by Administrator to Regional Center communication revealed that facility trash can was located under stove and Clients left posterior arm above elbow had a 3-inch burn with no blister. Clients Individual Program Plan (IPP) revealed that client is diagnosed with moderate intellectual disability and confirmed that client has “limited ability to express themselves to others in effective verbal manner. Client can be difficult to understand but also uses nonverbal communication cues to express themselves to others by using facial expressions, pointing, or leading individuals to desired item in question”. Client IPP also revealed that Client 1 has history of self injurious behavior of skin picking and hair plucking due to underlying anxiety order.

Based on observations during Initial virtual 10-day visit conducted on 6/23/20, LPA’s observed Client 1 to be in good spirits as evidenced by smiles and working on crafts. During time of initial visit, visit was conducted virtually via face time on phone due to Covid 19 precautions to which LPA’s did not observe burn on client’s anterior view of arms. No health and safety concerns were noted during that time of visit as well as follow up visit conducted on 11/17/22. Facility had additional visits in person on 8/23/21 (annual visit), 10/18/21 (health and safety case management) and 8/3/22 annual visit to which all three visits had no health/safety concerns as well as no deficiencies noted. CONTINUED ON 9099C

SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Jenifer Tirre
LICENSING EVALUATOR SIGNATURE:	DATE: 09/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2023

LIC9099 (FAS) - (06/04)

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Control Number 22-AS-20200616163352

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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

FACILITY NAME: CATHERINE'S RESIDENTIAL CARE HOME	FACILITY NUMBER: 306004662
	VISIT DATE: 09/06/2023

NARRATIVE

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Observations revealed that during in person visit on 11/17/22, facility stove had tin burner covers placed over burner ranges. Same observation made of trash can under stove provided photos in which burners have same covers placed over burners. During visit on 11/17/22 client 1 showed LPA forearms to which LPA did not observe any visible marking's.

Based off interviews, documents reviewed and observations, the allegations that Facility staff held residents’ arm over flame on stove, Administrator asked resident not to tell anyone about incident and two staff hitting residents are deemed UNSUBSTANTIATED.

Although the allegations may have happened or is valid there is no preponderance of evidence to prove the alleged violations did or did not occur.

An exit interview was conducted with Administrator Michael San Diego and a copy of report along with a LIC 811 confidential names list was provided to Administrator.

SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Jenifer Tirre
LICENSING EVALUATOR SIGNATURE:	DATE: 09/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2023

LIC9099 (FAS) - (06/04)

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