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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005616
Report Date: 02/23/2024
Date Signed: 02/23/2024 04:14:54 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
05/09/2022 and conducted by Evaluator Andrea Mendivil
COMPLAINT CONTROL NUMBER: 22-AS-20220509093957
FACILITY NAME:NEW JOURNEYS BEHAVIORAL HEALTHFACILITY NUMBER:
306005616
ADMINISTRATOR:KHARBANDA, ANDYFACILITY TYPE:
772
ADDRESS:7 MASLOWTELEPHONE:
(949) 336-6460
CITY:IRVINESTATE: CAZIP CODE:
92620
CAPACITY:6CENSUS: 4DATE:
02/23/2024
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Erin Bull - Program Director TIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Staff did not prevent residents from engaging in inappropriate behaviors
Staff did not prevent resident from wandering from the facility
Staff did not keep residents personal information confidential
Staff are falsifying residents documents
Staff are not properly reporting incidents regarding residents
INVESTIGATION FINDINGS:
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On this day, Licensing Program Analyst (LPA) Andrea Mendivil made an unannounced visit to deliver complaint findings. LPA was greeted and granted entry into the facility by Program Director Erin Bull and explained the reason for the visit.

The Department received a complaint on 05/09/2022 and LPA Mendivil conducted the initial 10-day visit on 05/12/2022. During the visit LPA Mendivil obtained copies of pertinent documents including client records, incident reports and medication administration records. Regarding the allegations facility staff did not prevent residents from engaging in inappropriate behaviors, staff did not prevent residents from wandering from the facility, staff did not keep residents’ personal information confidential, staff are falsifying residents’ documents and staff are not properly reporting incidents regarding residents, the investigation revealed the following:
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Andrea Mendivil
LICENSING EVALUATOR SIGNATURE:

DATE: 02/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2024
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-20220509093957
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: NEW JOURNEYS BEHAVIORAL HEALTH
FACILITY NUMBER: 306005616
VISIT DATE: 02/23/2024
NARRATIVE
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Regarding the allegation that staff did not prevent residents from engaging in inappropriate behavior using illegal drugs. Based on interviews with 5 out of 5 staff, staff reported during intake they review all client’s belongings and wash their clothes. The department received an LIC 624 on 07/04/2022 reporting that C1 had brought in fentanyl stored in their rectum into the facility. The facility was only made aware when the client self-reported after C1 had an incident with the drug. Facility staff then submitted the Unusual Incident Report LIC 624 to the Department. Based on clients’ interviews 4 out of 5 clients reported that they do not have access to drugs while in care, the final client reported they witnessed it outside of the facility.

The allegation that staff did not prevent clients from wandering from the facility. Based on interviews with Program Director Erin Franco reported that there has only been 1 elopement, which the facility self-reported on 03/07/2022. Interviews with 4 out 5 clients revealed the clients would need prior approval to leave the facility or they would be escorted by facility staff.

For the allegation the staff did not keep resident’s personal information confidential. Based on interviews with 4 out 5 clients, all reported they felt their information was safeguarded. In interviews with 5 out of 5 staff all staff indicated client’s records are kept electronically and there is no paper documents.

Regarding the allegation staff are falsifying residents’ documents. Based on interviews with 5 out of 5 staff, all documents are scanned into the system directly as is and discard by shredding. It was alleged that the client signed for their conservator, however the LPA observed no clients being under conservatorship.

For the allegation staff are not properly reporting incidents regarding residents, the referenced incident on 03/15/2022 where client hit the staff was reported to the department on 03/16/2022.

Based on the preponderance of evidence the allegations facility staff did not prevent residents from engaging in inappropriate behaviors, staff did not prevent residents from wandering from the facility, staff did not keep residents personal information confidential, staff are falsifying residents documents, and staff are not properly reporting incidents regarding residents are found to be UNSUBSTANTIATED, meaning 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. This agency has investigated this complaint and an exit interview was conducted with facility and a copy of this report and LIC 811 was provided at the time of exit.

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Andrea Mendivil
LICENSING EVALUATOR SIGNATURE:

DATE: 02/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2