331881012-9-20-2024-18-AS-TDAN-DADVPA-20241025163624

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 331881012
Report Date: 09/20/2024
Date Signed: 09/20/2024 03:42:55 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 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
08/30/2024 and conducted by Evaluator Janira Arreola

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20240830140722

FACILITY NAME:	LOVABLE HOME CARE FOR DISABLED ADULTS		FACILITY NUMBER:	331881012
ADMINISTRATOR:	SEYMORE, TONISHA		FACILITY TYPE:	735
ADDRESS:	26594 BYRON CIRCLE		TELEPHONE:	(714) 341-4542
CITY:	MENIFEE	STATE: CA	ZIP CODE:	92584
CAPACITY:	4	CENSUS: 4	DATE:	09/20/2024
		UNANNOUNCED	TIME BEGAN:	02:30 PM
MET WITH:	Administrator, Tonisha Seymore		TIME COMPLETED:	03:50 PM

ALLEGATION(S):

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Client sustained unexplained injuries while in care

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Janira Arreola, conducted an unannounced visit to the facility in order to investigate the above allegations. LPA met with Administrator, Tonisha Seymore, who was informed of the purpose of the visit. During the investigation LPA conducted interviews, conducted a walk through, and conducted records reviews.

It was alleged that “Client sustained unexplained injuries while in care”. It was alleged Client #1 (C1) had sustained injuries while at the facility, the morning of 8/29/2024. LPA received photos of the alleged injuries, which revealed the client had red mark on their upper arm, scratches on the right elbow surrounded by purple bruise, redness on the cheek bones on C1’s left and right side, and scratch on the side of the C1’s nose.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE:	DATE: 09/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2024

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-20240830140722

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: LOVABLE HOME CARE FOR DISABLED ADULTS	FACILITY NUMBER: 331881012
	VISIT DATE: 09/20/2024

NARRATIVE

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LPA conducted interviews with (2) outside sources. (1) interview revealed C1 was observed with injuries the morning of 8/29/2024, when C1 was placed on transportation to their day program. Interview revealed C1 had not been observed engaging in any behaviors or incidents between the time C1 was transported from their home to the day program on 8/29/2024. (1) interview revealed C1 engages in self injurious behaviors and has a 1:1 when they are at their home but not at their day program or on transportation. Interview revealed the injuries observed in the photographs were consistent with self injurious behaviors C1 engages in.

LPA conducted (2) client interviews. (1) client was unable to provide information on the allegation, and (1) client had no knowledge of C1 being injured. LPA conducted (2) facility staff interviews. (Staff revealed that C1 has self injurious behaviors where they hit their head, elbows and scratch their face and body. Staff revealed on 8/29/2024, C1’s had a 1:1 staff who observed and monitored C1 while engaging in self injurious behaviors. Staff provided LPA with (2) videos of C1 when they engage in self injurious behaviors. The videos were consistent with LPA observations during on site visit 9/5/2024. LPA witnessed C1 attempting to hit their face and cheek bones resulting in redness in the clients cheeks during the visit.

LPA reviewed C1’s Individualized Program Plan (IPP) and confirmed C1 has a 1:1 for behavior supports at their residential facility, and self- injurious behaviors such as head banging, and elbowing. LPA reviewed behavior tracking log for C1, where it is documented “self injurious behavior” is defined when C1 strikes their head or facial area against surfaces, strikes themselves, pinches or bites themselves. On 8/29/2024, behavior tracking log and “ABC” sheet documented C1 had (2) instances of self injurious behavior in the morning.

Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. An exit interview was conducted, and a copy of this report was provided.

SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE:	DATE: 09/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2024

LIC9099 (FAS) - (06/04)

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