331880894-12-9-2021-18-AS-KCLS-C9SQZS-20211217113712

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 331880894
Report Date: 03/09/2021
Date Signed: 12/09/2021 03:20:47 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, 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
03/08/2021 and conducted by Evaluator Javier Prieto

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20210308084951

FACILITY NAME:	PLEASANT WAYS ADULT RESIDENTIAL		FACILITY NUMBER:	331880894
ADMINISTRATOR:	WALKER, KEITH		FACILITY TYPE:	735
ADDRESS:	761 AMOR DR.		TELEPHONE:	(951) 312-1751
CITY:	SAN JACINTO	STATE: CA	ZIP CODE:	92582
CAPACITY:	4	CENSUS: 3	DATE:	03/09/2021
		UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Keith Walker		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Facility is not providing adequate supervision per agreement.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Javier Prieto conducted a complaint investigation alleging “Facility is not providing adequate supervision per agreement”. Due to COVID 19 and social distancing the complaint was conducted, via telephone. LPA identified himself and discussed the purpose of the call and the elements of the allegation with the Administrator Keith Walker. Walker states resident #1 (R1) has a 1:1 staff supervision. On 03/09/2021, R1 was in the bathroom, locked the door and caused self-injury while locked in facility’s bathroom. R1 was sent to the hospital and placed on a 5150 hold. This was reported to R1’s Placement agency, and CCL via special incident report (SIR). Review of R1’s facility file documents revealed a history of behavioral, and self-injury. R1 was moved from facility at time of investigation and not available for interview.

Based on the information obtained there is not enough evidence that facility is not providing adequate supervision per agreement. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Javier Prieto
LICENSING EVALUATOR SIGNATURE:	DATE: 03/09/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/09/2021

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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