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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 336423469
Report Date: 05/09/2024
Date Signed: 05/09/2024 10:39:04 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 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
01/30/2024 and conducted by Evaluator Paola Guerrero
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20240130084100
FACILITY NAME:NEW DISCOVERY RESIDENTIAL SERVICES #4FACILITY NUMBER:
336423469
ADMINISTRATOR:DONNA WELDONFACILITY TYPE:
735
ADDRESS:903 UNION ST.TELEPHONE:
(951) 381-4130
CITY:BEAUMONTSTATE: CAZIP CODE:
92223
CAPACITY:4CENSUS: 3DATE:
05/09/2024
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Vivian FranciscoTIME COMPLETED:
11:00 AM
ALLEGATION(S):
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Staff did not prevent a resident from sustaining a fracture.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Paola Guerrero conducted an unannounced visit to deliver findings on the allegation listed above. LPA met with Facility Administrator and explained the purpose of the visit. The investigation consisted of interviews and review of records.

First allegation, Staff did not prevent a resident from sustaining a fracture. During record review it was revealed that client #1 had sustained a foot fracture in October 21,2023. LPA conducted a record review, and it was revealed that no assessment or mitigation plan was established to help prevent Client #1 from sustaining future injuries. In January 18,2024 Client #1 sustained a second fracture, unknown where it occurred, staff indicated not knowing how Client #1 might have sustained the injury. Staff stated that Client #1 has the tendency of kicking furniture and believes that could have been a contributing factor to Client #1 sustaining a second fracture. Based on the evidence gathered during the investigation, the above allegation is Substantiated.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Paola Guerrero
LICENSING EVALUATOR SIGNATURE:

DATE: 05/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2024
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-20240130084100
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: NEW DISCOVERY RESIDENTIAL SERVICES #4
FACILITY NUMBER: 336423469
VISIT DATE: 05/09/2024
NARRATIVE
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Substantiated A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Title 22 regulations, Observation of the Client 85075.4(a)(b), from division 6, chapter, article 6, is being cited on the attached LIC 9099 D.

An exit interview was conducted where this report (LIC 9099) was discussed, and a copy was provided, along with a copy of the appeal rights. to Facility Administrator Vivian Francisco at the end of the visit.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Paola Guerrero
LICENSING EVALUATOR SIGNATURE:

DATE: 05/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 56-AS-20240130084100
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: NEW DISCOVERY RESIDENTIAL SERVICES #4
FACILITY NUMBER: 336423469
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/09/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/31/2024
Section Cited
CCR
85075.4(a)(b)
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Observation of the Client (a) The license shall regularly observe each client for changes in physical, mental, emotional, and social functioning... (b) The licensee shall provide assistance when observation reveals needs which might require a change in the existing level of service, or possible discharge or transfer to another type of facility.

This requirement is not met as evidence by:
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The Licensee/Administrator has agreed to review "Observation of the Client" regulation and provide training to all support staff to ensure that the safety and needs of the client are being met daily. Proof of training and signed document by all staff will be provided to LPA on POC date 5/31/2024.

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Based on interviews, record review, the licensee did not ensure that the Observation of the Client was obtained to help prevent Client #1 from sustaining a second fracture, which poses an immediate Health, Safety, or Personal Rights risk to persons in care.
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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: Efren Malagon
LICENSING EVALUATOR NAME: Paola Guerrero
LICENSING EVALUATOR SIGNATURE:

DATE: 05/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3