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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 330910676
Report Date: 12/07/2022
Date Signed: 12/07/2022 02:01:40 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, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/05/2022 and conducted by Evaluator Amy Goldenberg
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20220805121629
FACILITY NAME:J & S BOARD & CAREFACILITY NUMBER:
330910676
ADMINISTRATOR:SUSAN PRIORFACILITY TYPE:
735
ADDRESS:11334 58TH STREETTELEPHONE:
(951) 360-1287
CITY:MIRA LOMASTATE: CAZIP CODE:
91752
CAPACITY:6CENSUS: 4DATE:
12/07/2022
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Karina Crumbley, CaregiverTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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-Staff did not follow Covid-19 safety protocols.
-Staff did not seek timely medical attention for resident in care.
INVESTIGATION FINDINGS:
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This unannounced visit by Amy Goldenberg, Licensing Program Analyst (LPA), is being conducted to conclude this agency’s investigation into the complaint allegations mentioned above.

During the course of this investigation LPA interviewed two facility staff, one resident, and three witnesses. LPA collected C1 records pertinent to the investigation. Regarding the allegations staff did not follow Covid-19 safety protocols and staff did not seek timely medical attention for resident in care investigation revealed the following information: LPA learned C1 visited their sister out of town for a couple of days then returned home 8/2/2022. C1 was reported to have the symptom of a cough upon return to the facility by family according to S1 and as documented in the facility progress notes. C1 client note dated 08/02/2022 indicated that C1's family member texted to say that C1 had a mild cough. Facility staff did not have C1 tested for COVID-19 or isolate C1 upon their return following hearing that C1 was having symptoms.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amy Goldenberg
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)
Page: 1 of 3
Control Number 56-AS-20220805121629
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME: J & S BOARD & CARE
FACILITY NUMBER: 330910676
VISIT DATE: 12/07/2022
NARRATIVE
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S1 reports that they did not notify C1’s physician or attempt to obtain C1 a Covid-19 test upon returning from their family visit with reported symptoms. On 8/3/2022 C1 was allowed to go to day program. On 8/3/2022 C1 tested positive for Covid-19 virus during day program hours. Three (3) of three (3) witness interviewed reported that C1 stated that they told them that facility staff made him come to work, that C1 looked unwell upon arrival to the faciltiy and that C1 states he reported their symptoms to the facility staff before coming. The day program decided to isolate C1 in the program's isolation room and provided C1 with a rapid Covid test based on their appearance and complaints of symptoms according to three (3) of three (3) witness interviewed. Day program staff called the facility to have C1 picked up and were told that the staff could not have contact with a COVID resident due to their own medical issues. The facility sent an UBER to come pick up C1. Day program staff informed the driver of the COVID-19 status and the driver declined service. C1 was picked up after two hours by the Licensee. Based on the available information, LPA has determined that the facility failed to follow Covid-19 safety protocols and did not seek timely medical attention for C1 following report of symptoms and positive test result.

We have substantiated the complaint allegations as valid and that a violation has occurred based on the preponderance of available evidence. A copy of this report along with appeal rights are being reviewed with, and furnished to the facility representative. Please see LIC 9099D. A copy of this report along with appeal rights are being reviewed with and furnished to the facility representative.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amy Goldenberg
LICENSING EVALUATOR SIGNATURE:

DATE: 12/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/07/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3
Control Number 56-AS-20220805121629
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: J & S BOARD & CARE
FACILITY NUMBER: 330910676
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/07/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/08/2022
Section Cited
CCR
80075(a)
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The licensee shall ensure that each client receives necessary first aid and other needed medical... including arrangement for and/or provision of transportation to the nearest available services.
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Licensee to retrain all employees in the areas of Covid-19 safety protocols and develop a plan for timely client pick up from day program in the event a medical issue arises.
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The facility did not meet this requirement as evidenced by C1 having COVID symptoms and being sent to their day program without proper testing and C1 not being picked up for over two hours after positive test results.
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Please submit LIC 9098 by 12/08/2022.
Type A
01/12/2023
Section Cited
CCR
85022(a)(1)
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Plan of Operation In addition to Section 80022, the following shall apply.The plan of operation and related materials shall contain the Infection Control Plan pursuant to Section 85095.5(c)
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 Licensee to retrain all employees in the areas of Covid-19 safety protocols as outlined in the plan of operations. Please submit LIC 9098 by 12/08/2022.
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The facility did not meet this requirement as evidenced by C1 being sent to day program following reports of Covid symptoms following leave from the facility.
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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: Nedra Brown
LICENSING EVALUATOR NAME: Amy Goldenberg
LICENSING EVALUATOR SIGNATURE:

DATE: 12/07/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/07/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3