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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331800484
Report Date: 06/08/2021
Date Signed: 04/15/2023 11:23:11 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
RIVERSIDE, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/07/2021 and conducted by Evaluator Shaunte Henry
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20210607090221
FACILITY NAME:VIA GENOAFACILITY NUMBER:
331800484
ADMINISTRATOR:EDGINGTON, JOHN TFACILITY TYPE:
735
ADDRESS:47018 VIA GENOATELEPHONE:
(760) 262-5957
CITY:INDIOSTATE: CAZIP CODE:
92201
CAPACITY:4CENSUS: 4DATE:
06/08/2021
UNANNOUNCEDTIME BEGAN:
01:35 PM
MET WITH:Nicole Lara, DSPTIME COMPLETED:
02:15 PM
ALLEGATION(S):
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Staff locked resident in their room
INVESTIGATION FINDINGS:
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**This is a copy of Original 9099 dated 6/08/2021, investigation conducted by LPA Shaunte Henry and Anna Bueno**
On 6/8/21 Licensing Program Analysts (LPA) Shaunte Henry and Anna Bueno conducted an unannounced visit in order to initiate an investigation into the above allegation. LPAs spoke to DSP, Nicole Lara, explained the purpose of the visit and were granted entry.
The investigation, which consisted of interviews and document review revealed the following:
Staff locked resident in their room. An interview with the administrator revealed that Staff 1 (S1) locked Client 1 (C1) in his bedroom because of a behavior episode while S1 was attempting to prepare medication. The administrator counseled S1 and provided training to address their actions.
Based on LPAs observations and interviews, which were conducted, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED.
An exit interview was conducted where this report was provided to licensee/administrator John Edgington.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Bernadette Allen
LICENSING EVALUATOR SIGNATURE:

DATE: 06/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/08/2021
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 18-AS-20210607090221
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
RIVERSIDE, CA 92507

FACILITY NAME: VIA GENOA
FACILITY NUMBER: 331800484
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/08/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/15/2021
Section Cited
CCR
80072(a)(3)
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PERSONAL RIGHTS each client shall have personal rights which include, but are not limited to, the following: To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse, or other actions of a punitive nature. This requirement was not met as evidenced by:
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The licensee will ensure that stff are trained in protecting the personal rights of all clients. The licensee will read the regulation entirely and provide a written statement of understanding and also provide proof of training to the department by the POC date 6/15/2021.
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Interviews and record review revealed that Staff 1 (S1) did lock Client 1 (C1) in their bedroom because C1 was having a behavior episode and S1 was preparing medication.

This poses a potential personal rights risk to C1.
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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: Karen Clemons
LICENSING EVALUATOR NAME: Bernadette Allen
LICENSING EVALUATOR SIGNATURE:

DATE: 06/08/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/08/2021
LIC9099 (FAS) - (06/04)
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