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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306006115
Report Date: 06/14/2023
Date Signed: 06/14/2023 10:55:34 AM

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
05/18/2023 and conducted by Evaluator Kimberly Lyman
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20230518160047
FACILITY NAME:T3 ADULT CARE RESIDENTIAL CAREFACILITY NUMBER:
306006115
ADMINISTRATOR:WILLIAMS, GLORIAFACILITY TYPE:
735
ADDRESS:1726 SOUTH LATUS PLACETELEPHONE:
(714) 797-6057
CITY:ANAHEIMSTATE: CAZIP CODE:
92804
CAPACITY:4CENSUS: 3DATE:
06/14/2023
UNANNOUNCEDTIME BEGAN:
10:04 AM
MET WITH:Thien LuuTIME COMPLETED:
10:30 AM
ALLEGATION(S):
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Facility failed to ensure a safe environment for a client, resulting in self-harm
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced complaint visit to deliver findings on the above allegation. LPA was greeted and granted entry into the facility and explained the reason for the visit.
During the course of the investigation, LPA toured the facility and interviewed staff, clients and witnesses. Regarding the allegation that facility failed to ensure a safe environment for a client, resulting in self-harm, the investigation revealed the following: Client 1 (C1) expressed interest in a sexual relationship with C2. C2 denied the interest resulting in a contentious relationship between the two clients. During an outing to Costco on May 14, 2023, the two clients engaged in a verbal argument which resulted in C2 pushing C1. All parties indicate there were no injuries. Due to the contentious relationship between the clients, witnesses indicate C1 had self-harmed resulting in a scratch on the neck. C1 denies the scratch or any self harm/ suicidal ideations. Licensee indicates working with C1's psychologist as well as constant monitoring of the client to ensure safety. Licensee states sweeping the client's room multiple times daily to monitor client. CONTINUED ON LIC 9099C DATED 06/14/2023.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE:

DATE: 06/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2023
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-20230518160047
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: T3 ADULT CARE RESIDENTIAL CARE
FACILITY NUMBER: 306006115
VISIT DATE: 06/14/2023
NARRATIVE
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C1's behavioral consultant indicates a need for a higher level of care and the whole care team is working with OC Regional Center for a different placement. Licensee has provided a thirty day notice to client, Licensing and Regional Center. C1 is diagnosed with long standing depression, obsessive compulsive disorder, bi-polar disease, delusions and body dysmorphia. Due to conflicting information, LPA is unable to confirm allegation. Therefore, the allegation is deemed unsubstantiated, meaning that although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview conducted and a copy of this report was left at the facility.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE:

DATE: 06/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2