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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 04:16:42 PM

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
05/09/2022 and conducted by Evaluator Andrea Mendivil
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20220509160350
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:
02:31 PM
MET WITH:Erin Bull - Program Director TIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Client was not provided medications as prescribed
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 Staff and explained the reason for the visit.

On 05/09/2022 the department received allegations that the client was not provided medication as prescribed. During the course of the investigation, the Department interviewed staff and clients as well as reviewed and obtained pertinent documentation such client records, incident reports, medication administration records, medication orders. Regarding the allegation client was not provided medication as prescribed, the investigation revealed the following:
Client 1 (C1) was prescribed medication Quetiapine Fumarate 50mg, Prazosin 1MG, Propranlol 20MG, prescribed on 03/09/2022. Medication record for C1 documents medication provided from 04/18/2022 to 05/05/2022. C1 left the facility on 05/06/2022.
Substantiated
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 5
Control Number 22-AS-20220509160350
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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 Administrator Andy Kharbanda and Former Program Director Erin Franco admitted to not giving medication to the client at the time of discharge due to the discharge was not planned. Administrator and Program Director indicated medical staff did not want to be responsible for client having medication that could be used inappropriately outside of the facility.

Current Program Director Erin Bull stated the facility is providing all prescribed medication to clients in care even if the discharge is against clinical advise.

Based on the preponderance of evidence through record review and interviews, the allegation client was not provided medication as prescribed is determined to be SUBSTANTIATED, meaning a violation has occurred.

The following is being cited per California Code of Regulations Title 22 Division 6 Chapter 8.

An exit interview was conducted and a copy of this report and appeal rights was provided to the facility representative.

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 5
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-20220509160350

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:
02:31 PM
MET WITH:Erin Bull - Program Director TIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Clients have access to illegal drugs while in care
Staff do not meet the appropriate ratios for the clients
Staff mishandled a client's medications while in care
Staff do not ensure the clients are properly fed while in care
INVESTIGATION FINDINGS:
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On this day, Licensing Program Analyst (LPA) Andrea Mendivil made an unannounced visit to deliver complaint findings. LPA Mendivil was greeted and granted into the facility Staff and explained the reason for the visit.

On 05/09/2022 the Department received allegations that facility allows clients to have access to illegal drugs while in care, staff do not meet the appropriate ratios for the clients, staff mishandled client’s medication while in care, and staff do not ensure clients are properly fed while in care.

During the course of the investigation, the Department interviewed staff and clients as well as reviewed and obtained pertinent documentation such client records, incident reports, medication administration records, sample menus and grocery list.
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: 3 of 5
Control Number 22-AS-20220509160350
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 the facility allows clients to have access to illegal drugs while in care based on clients’ interviews 4 out of 5 clients reported that they do not have access to drugs while in care. Interviews with staff revealed that upon intake to the facility, facility staff will review client’s belongings for items such as drugs or contraband. The 1 out of 5 clients reported witnessing the illegal drug use outside of the facility. The Department received an Unusual Incident Report (LIC 624) dated 07/04/2022 from the facility where Client 2 (C2) reported to staff that they had put fentanyl up their rectum prior to admission and that they had used it. Staff did not have knowledge of the fentanyl until after the incident had occurred and client reported to staff they had brought it in.

In relation to staff do not meet the appropriate ratios for the clients, based on interviews with staff, clients, and review of LIC 500 dated 5/12/2022 and staff schedules for the month of May 2022 there is at least one staff member for every 2 clients which follows regulations.

Based on medication records for C1, client was given medications prescribed by facility physician including medications that were previously prescribed by prior facility. Interviews with 4 out of 5 clients reported they have not had issues with receiving their medications while in care.

For the allegation that the staff do not ensure the clients are properly fed while in care. LPA observed food present at the facility within the regulation of 2 days perishable and 7-day nonperishable. LPA reviewed the facility grocery list that matched planned menus with appropriate FDA standards. Interviews with 4 out of 5 clients reported that the facility follow the menu, however they also order out based on client’s wishes.

Based on the preponderance of evidence the allegations are determined as follows; facility allows clients to have access to illegal drugs while in care, staff do not meet the appropriate ratios for the clients, staff mishandled client’s medication while in care, and staff do not ensure clients are properly fed while in care are determined 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 Program Director 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: 4 of 5
Control Number 22-AS-20220509160350
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/23/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/04/2024
Section Cited
CCR
81072(a)(3)
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(a) Each client shall have personal rights which include, but are not limited to, the following:(3) To be free from corporal or unusual punishment..., including but not limited to
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Per current Program Director facility is providing at clients their medications at time of discharge, therefore violation has been corrected.
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: interference with the daily living functions, including eating, sleeping, or toileting; or withholding of shelter, clothing, medication or aids to physical functioning. This requirement was not met as evidence by, Adminstrator and former Program Director stated they did not provide medicaitons to C1 at discharge.
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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: Alisa Ortiz
LICENSING EVALUATOR NAME: Andrea Mendivil
LICENSING EVALUATOR SIGNATURE:

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

DATE: 02/23/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5