331880909-11-8-2021-18-AS-NBRN-C8PRXB-20211112122424

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 331880909
Report Date: 11/08/2021
Date Signed: 11/08/2021 09:46:21 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, 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
06/14/2021 and conducted by Evaluator Shaunte Henry

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20210614142728

FACILITY NAME:	VELASCO HOME		FACILITY NUMBER:	331880909
ADMINISTRATOR:	SAENZ, ISAIAH		FACILITY TYPE:	735
ADDRESS:	51320 AVENIDA VELASCO		TELEPHONE:	(760) 972-4355
CITY:	LA QUINTA	STATE: CA	ZIP CODE:	92253
CAPACITY:	4	CENSUS: 4	DATE:	11/08/2021
		UNANNOUNCED	TIME BEGAN:	09:40 AM
MET WITH:	Nicole Lara, House Manager		TIME COMPLETED:	10:00 AM

ALLEGATION(S):

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Facility staff did not adequately supervise resident in care

INVESTIGATION FINDINGS:

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On 11/8/21 Licensing Program Analyst (LPA) Shaunte Henry conducted an unannounced visit for the purpose of delivering the findings to the above allegations. The LPA met with Nicole Lara, explained the nature of the visit and was granted entry.

The investigation, which consisted of interviews and file review revealed the following:
The licensee reported that on 6/11/21 Resident 1 (R1) began displaying aggressive behavior. Staff 1 (S1) was present and made attempts to calm R1 down. R1 made threats to harm theirself. R1 went into their room and began pounding their head into the wall, which resulted in an injury and bleeding. R1 was immediately transported to the hospital via ambulance.

***Continued on 9099C***

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Shaunte Henry
LICENSING EVALUATOR SIGNATURE:	DATE: 11/08/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2021

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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Control Number 18-AS-20210614142728

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: VELASCO HOME	FACILITY NUMBER: 331880909
	VISIT DATE: 11/08/2021

NARRATIVE

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***Continued from 9099***

Staff 1 (S1), who is staff that was a witness to the incident confirmed that R1 was displaying aggressive behavior and pounded his head on the wall. The incident was reported to Inland Regional Center (IRC) and Community Care Licensing (CCL).

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 at this time.

An exit interview was conducted where this report was provided to John Edgington via email.

SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Shaunte Henry
LICENSING EVALUATOR SIGNATURE:	DATE: 11/08/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2021

LIC9099 (FAS) - (06/04)

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