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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 336425347
Report Date: 02/13/2024
Date Signed: 02/13/2024 12:02:36 PM

Substantiated


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
01/23/2024 and conducted by Evaluator Janette Romero
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20240123141432
FACILITY NAME:KAISER ADULT BEHAVIORAL CENTER TEMECULAFACILITY NUMBER:
336425347
ADMINISTRATOR:SOUZA, SHARIFACILITY TYPE:
775
ADDRESS:27496 COMMERCE CENTER DR STE HTELEPHONE:
(951) 225-2632
CITY:TEMECULASTATE: CAZIP CODE:
92590
CAPACITY:60CENSUS: 28DATE:
02/13/2024
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Administrator, Shakilla WilliamsTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Client sustained an injury while in care
Staff did not ensure care and supervision was provided to client
INVESTIGATION FINDINGS:
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On 2/13/2024, Licensing Program Analyst (LPA) Janette Romero conducted an unannounced visit to conclude the investigation into allegations listed above. LPA met with Administrator, Shakilla Williams who was informed of the purpose of the visit.

It was reported that Client 1’s (C1’s) board and care facility observed a scratch and bruise on C1 upon arrival from day program on 1/8/2024. C1’s board and care facility reported their observations to C1’s day program staff. It was alleged that Staff 1 (S1) witnessed Staff 2 (S2) leave C1 unattended, which resulted in C1 falling out of their wheelchair and sustaining the scratch and bruise. LPA visited the facility, conducted staff, client, and witness interviews, and reviewed pertinent records.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Janette Romero
LICENSING EVALUATOR SIGNATURE:

DATE: 02/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/13/2024
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 18-AS-20240123141432
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: KAISER ADULT BEHAVIORAL CENTER TEMECULA
FACILITY NUMBER: 336425347
VISIT DATE: 02/13/2024
NARRATIVE
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LPA reviewed C1’s Individual Program Plan, which notes that C1 requires constant supervision during waking hours to prevent injury/harm in all settings/situations as C1 does not possess or exercise appropriate safety awareness. LPA reviewed the facility's program statement which notes the staffing schedule at People’s Care Temecula Community Program is based on a 1:3 ratio.

Regarding the allegation, “Staff did not ensure care and supervision was provided to the client”, LPA interviewed S1 who reported they were in the art room with their three (3) assigned clients when they witnessed S2 relieve Staff 3 (S3) from their duties of supervising C1. S1 reported they were in the art room with S2 and C1 when they witnessed S2 leave the room, leaving C1 unsupervised. LPA interviewed S2 who confirmed supervising C1 on 1/8/2024 after S3 left early. S2 reported only assisting C1 with incontinence needs and getting into the transportation van, and listed Staff 4 (S4) as a possible witness. LPA was unable to corroborate the information provided by S2. S2 denied being in the art room with C1; however, interviews revealed S2 was observed with C1 in the art room and walking around the facility after S3 left early on 1/8/2024. Based on interviews conducted, this allegation is Substantiated.

Regarding the allegation, “Client sustained injury while in care”, S1 reported that after S2 left C1 unsupervised, S1 witnessed C1 stand up on their own from their wheelchair and fall back. S1 reported they ran to assist C1 up and observed C1 sustained a scratch and redness on their back from the fall. C1’s board and care facility reported they conduct client body checks before clients leave to day program and upon arrival from day program. LPA reviewed C1’s board and care facility’s Body Check Logs (BCLs). The BCL for C1 dated 1/8/2024 at 7:00 a.m. did not state observation of a bruise/scratch. The BCL dated 1/8/2024, at 5:00 p.m., notes that C1 was observed to have a scratch. The BLC dated the following day, 1/9/2024 at 7:00 a.m., notes observation of a bruise on the scratch. LPA also reviewed a photograph of the scratch and bruise observed on C1 upon arriving from day program on 1/8/2024. Based on interviews conducted and record review, this allegation is Substantiated.

An exit interview was conducted and this report was reviewed and provided to Administrator Williams along with a Confidential Names List (LIC811), LIC9099-D, and Appeal Rights.

SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Janette Romero
LICENSING EVALUATOR SIGNATURE:

DATE: 02/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/13/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 18-AS-20240123141432
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: KAISER ADULT BEHAVIORAL CENTER TEMECULA
FACILITY NUMBER: 336425347
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/13/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/23/2024
Section Cited
CCR
82078(a)
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(a) The licensee shall provide care and supervision necessary to meet the client's needs and all services specified in the admission agreement.
This requirement was not met as evidenced by:
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Administrator stated the facility will provide in service training emphasizing client care and supervision. Proof of correction to be submitted to LPA by close of business on POC due date.
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During the complaint investigation, LPA determined S2 left C1 unsupervised, which resulted in C1 falling out of their wheelchair and sustaining a scratch and bruise. This poses a potential health and safety risk to clients 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: Jazmond D Harris
LICENSING EVALUATOR NAME: Janette Romero
LICENSING EVALUATOR SIGNATURE:

DATE: 02/13/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/13/2024
LIC9099 (FAS) - (06/04)
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