306005554-5-30-2023-22-AS-SSAS-CSCQ6X-20230531115415

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005554
Report Date: 05/30/2023
Date Signed: 05/30/2023 09:09:56 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
11/14/2022 and conducted by Evaluator Jessica Cho

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20221114160212

FACILITY NAME:	DEVOTED HEART CARE HOMES LLC		FACILITY NUMBER:	306005554
ADMINISTRATOR:	KEVIN CLARK		FACILITY TYPE:	735
ADDRESS:	26665 AVENIDA SHONTO		TELEPHONE:	(818) 384-9331
CITY:	MISSION VIEJO	STATE: CA	ZIP CODE:	92691
CAPACITY:	4	CENSUS: 2	DATE:	05/30/2023
		UNANNOUNCED	TIME BEGAN:	08:38 AM
MET WITH:	Rafael Carbajal		TIME COMPLETED:	09:20 AM

ALLEGATION(S):

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Client sustained abrasions to abdomen while in facility care.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Jessica Cho made an unannounced visit to deliver the findings into the above allegation. LPA met with Adminstrator (Admin) Rafael Carbajal and stated the purpose of the visit. On November 11, 2022, LPA Cho made the initial 10-day visit. The following are the findings of the investigation conducted by the Department which involved record review and interviews:

On November 14, 2022, the Department received a complaint of physical abuse. It was alleged that the client sustained abrasions to the abdomen while in facility care. Client 1 (C1) sustained three abrasions to the right flank and two abrasions under the left breast during a morning encounter between Staff 1 (S1) and C1. C1 is diagnosed with Mild Intellectual Delay and Angelman’s Syndrome and has a history of displaying challenging behaviors such as physical aggression which includes pulling other people’s hair as documented on the Second Quarter Behavior Report dated September 16, 2022. Based on the interview conducted by the Department, on November 11, 2022, approximately 10:00 am, Staff 1 (S1) assisted dressing C1 for the day. C1 refused to put on their socks and shoes, so S1 bent down to assist.

Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Jessica Cho
LICENSING EVALUATOR SIGNATURE:	DATE: 05/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2023

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-20221114160212

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: DEVOTED HEART CARE HOMES LLC	FACILITY NUMBER: 306005554
	VISIT DATE: 05/30/2023

NARRATIVE

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S1 indicated C1 grabbed S1’s hair with both hands. C1 did not comply when S1 verbally prompted C1 to release the hold of the hair, and it took four to five attempts to physically guide C1 to release the hair. S1 confirmed pushing C1 with one hand and in the process scratching C1 with their fingernails sustaining minor, linear abrasions to the upper extremities and right flank.

Due to S1’s admission to the physical altercation, LPA is able to corroborate the allegation as S1 failed to utilize proper disengaging and de-escalating techniques to resolve conflict resolution. Based on the information obtained through interviews and record review, the preponderance of evidence standard has been met, therefore the allegation of physical abuse is deemed SUBSTANTIATED. A deficiency is being cited as per Title 22, Division 6, Chapter 1 of the California Code of Regulations. See the attached LIC9099D.

An exit interview was conducted with Administrator Rafael Carbajal, and a copy of this report including the LIC9099C, LIC9099D, LIC811s, and the appeal rights were provided during this visit.

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Jessica Cho
LICENSING EVALUATOR SIGNATURE:	DATE: 05/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2023

LIC9099 (FAS) - (06/04)

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Control Number 22-AS-20221114160212

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: DEVOTED HEART CARE HOMES LLC	FACILITY NUMBER: 306005554
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/30/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 05/31/2023 Section Cited CCR 80072(a)(3)	1 2 3 4 5 6 7	Type A: 80072 Personal Rights (a) Except for children’s residential facilities, each client shall have personal rights which include, but are not limited to, the following: (3) To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse, or other actions of a punitive nature, including but not limited to: interference with the daily living functions, including eating, sleeping, or toileting; or withholding of shelter, clothing, medication or aids to physical functioning.	1 2 3 4 5 6 7	Licensee to submit a training plan covering topics but are not limited to proper de-escalating/disengaging techniques via email by POC due date,05/31/23, and to provide proof of trainings completed by all staff submitted to LPA via email by 06/06/2023.
	8 9 10 11 12 13 14	This requirement was not met as evidenced by: Based on the observations, interviews, review of records, and S1’s admission to the physical encounter, S1 failed to properly disengage and de-escalate C1 which poses an immediate Health, 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.

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Jessica Cho
LICENSING EVALUATOR SIGNATURE:	DATE: 05/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2023

LIC9099 (FAS) - (06/04)

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