306005705-12-6-2022-22-AS-SSAS-CM42HK-20221213162448

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005705
Report Date: 12/06/2022
Date Signed: 12/06/2022 12:39:43 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
06/17/2022 and conducted by Evaluator Kathrina Chin

COMPLAINT CONTROL NUMBER: 22-AS-20220617163740

FACILITY NAME:	EDWARD BOARD AND CARE HOME		FACILITY NUMBER:	306005705
ADMINISTRATOR:	HERNANDEZ, MARISA		FACILITY TYPE:	735
ADDRESS:	117 EDWARD AVE.		TELEPHONE:	(714) 290-3809
CITY:	FULLERTON	STATE: CA	ZIP CODE:	92833
CAPACITY:	4	CENSUS: 4	DATE:	12/06/2022
		UNANNOUNCED	TIME BEGAN:	11:30 AM
MET WITH:	Marisa Hernandez, Administrator		TIME COMPLETED:	01:00 PM

ALLEGATION(S):

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Facility staff failed to provide care and supervision resulting in client eloping.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Kathrina Chin made an unannounced visit to the facility to conclude a complaint investigation. LPA met and discussed the purpose of the visit with Justin Rodriguez, caregiver and spoke to Marisa Hernandez, Administrator on the telephone. It was alleged that staff should have followed R1 when R1 eloped from the facility on June 11, 2022.
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LPA Chin reviewed R1's Individual Program Plan(IPP) and it indicated that R1 is able to cross the streets and knows how to avoid cars. Quality Assurance Coodinator from RCOC stated that this Adult Residential Facility (ARF) has one staff at all times. Therefore, the one staff is unable to follow the resident. S1 was the only staff at the facility on June 11, 2022. S1 stated that R1 leaves the facility all the time.

(Continued on LIC 9099C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Kathrina Chin
LICENSING EVALUATOR SIGNATURE:	DATE: 12/06/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2022

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-20220617163740

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: EDWARD BOARD AND CARE HOME	FACILITY NUMBER: 306005705
	VISIT DATE: 12/06/2022

NARRATIVE

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S1 stated that R1 can come and go as he pleases. S1 told R1 not to leave but R1 wanted to leave. R1's responsible party called that R1 has not arrived at her home. R1 was considered AWOL on June 11, 2022 and R1 was reported to Fullerton Police Department as a missing person on the same day by Staff 2 (S2). It was later determined that R1 was struck by a vehicle on June 11, 2022 and was taken to a hospital. R1 was transferred to a skilled nursing facility afterwards.

The IPP dated 3/3/2022 indicated that R1 is independent. It further states that R1 is aware of his surroundings and he can look out for cars, cross the streets, and he is not too trusting of strangers. R1 was working for Del Taco on Saturdays and was laid off due to the COVID-19 pandemic.

LPA Chin interviewed Staff 2 and she reported that the facility has an open door policy, that she cannot stop or restrain an individual from leaving the facility. S2 further explained that the facility can only provide verbal prompts and provide support. LPA interviewed Staff 1 and Staff 3 and both stated that R1 went out to the community on his own and always returned to the facility. LPA Chin interviewed R2 who stated that he did not know R1.

Based on the information gathered during the investigation and review of all documents obtained, the allegation that facility staff failed to provide care and supervision resulting in client eloping is deemed Unsubstantiated.

Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violations occurred; therefore, this allegation is deemed Unsubstantiated.

An exit interview was conducted, appeal rights explained and a copy of this report was given to Justin Rodriguez, Administrator.

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Kathrina Chin
LICENSING EVALUATOR SIGNATURE:	DATE: 12/06/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2022

LIC9099 (FAS) - (06/04)

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