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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005301
Report Date: 09/21/2022
Date Signed: 09/21/2022 10:40:15 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
11/03/2021 and conducted by Evaluator Albert Marin
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20211103092301
FACILITY NAME:AMHS TELECARE TREEHOUSE CRISIS RESIDENTIAL-SOUTHFACILITY NUMBER:
306005301
ADMINISTRATOR:BRYAN SAWLSVILLEFACILITY TYPE:
772
ADDRESS:25402 PACIFICA AVENUETELEPHONE:
(949) 238-2400
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY:6CENSUS: DATE:
09/21/2022
UNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:TIME COMPLETED:
11:00 AM
ALLEGATION(S):
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Facility failed to provide adequate care and supervision that led to elopement of a client from the facility.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Albert Marin made an unannounced visit to deliver the findings for the investigation completed for the complaint filed last November 3, 2021 against the facility. Via phone, LPA spoke with Administrator (AD) Jacqueline Lara, stated the purpose of this visit, and discussed the findings.

On allegation that facility failed to provide adequate care and supervision that led to elopement of a client from the facility, the following are the findings. On October 22, 2021, Client 1 (C1) was admitted in the facility. Per physician’s report on admission stated, Client 1 had primary diagnosis of bipolar disorder. C1 was determined to be able to follow instructions and able to communicate. Per interviews, C1 had been observed to have agitation towards staff and other clients in care. On October 28, 2021, there were four staff members on the floor and six clients in care. C1 started to have an aggressive behavior towards staff members. C1 became assaultive towards stay, destroyed items in the property and ran away from the facility. No staff member supervised C1 after coming out of the facility. Emergency Medical Services located C1 in the neighborhood agitated and uncooperative. Based on observation, interviews and file review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. (Continuation in Page 2)

Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Albert Marin
LICENSING EVALUATOR SIGNATURE:

DATE: 09/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2022
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 22-AS-20211103092301
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: AMHS TELECARE TREEHOUSE CRISIS RESIDENTIAL-SOUTH
FACILITY NUMBER: 306005301
VISIT DATE: 09/21/2022
NARRATIVE
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Deficiency was observed, Citation was issued per Title 22 Division 6 of the California Code of Regulations.
LPA Marin conducted an exit interview with AD Lara; LPA discussed the deficiency, citation, appeal rights and civil penalty assessed.

LPA Marin conducted a phone exit interview with AD Lara; LPA discussed the deficiency, citation, appeal rights and civil penalty assessed. AD granted permission for staff to sign and receive the report. Copy of this report, deficiency page, appeal rights, and civil penalty assessment form were left in the facility.
SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Albert Marin
LICENSING EVALUATOR SIGNATURE:

DATE: 09/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 22-AS-20211103092301
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: AMHS TELECARE TREEHOUSE CRISIS RESIDENTIAL-SOUTH
FACILITY NUMBER: 306005301
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/21/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/22/2022
Section Cited
CCR
81065(a)
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81065 Personnel Requirements. Facility personnel shall be competent to provide the services necessary to meet individual client needs and shall, at all times, be employed in numbers necessary to meet such needs. This requirement was not met as evidenced by:
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Facility will ensure all clients supervise the clients in care at all times. Threat reduced. As plan of correction, facility will provide CCLD copy of the training on handling aggressive behaviors and elopement procedures. Proof of training will be provided to CCLD on or before 10/07/2022.
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Based on file review, and interviews, the facility missed to provide services necessary to meet individual client needs, and shall, at all times, be employed in numbers necessary to meet such needs. Client 1 had behavior episodes that results to getting out of the facility unattended. This posed immediate threat on the health and safety of the client in care.
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Immediate civil penalty was assessed.

Copy of the cited regulation was provided for full reference.
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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.
SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Albert Marin
LICENSING EVALUATOR SIGNATURE:

DATE: 09/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3