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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 336425347
Report Date: 03/25/2024
Date Signed: 03/25/2024 02:07:05 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
08/10/2023 and conducted by Evaluator Janette Romero
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20230810155706
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: 20DATE:
03/25/2024
UNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Administrator, Shakilla WilliamsTIME COMPLETED:
02:15 PM
ALLEGATION(S):
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5
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7
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9
Staff yell at clients
Staff do not follow resident care plans
Staff did not ensure clients were supervised appropriately
Clients not accorded dignity in relationships with staff
INVESTIGATION FINDINGS:
1
2
3
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5
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7
8
9
10
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13
On 3/25/2024, Licensing Program Analyst (LPA) Janette Romero arrived unannounced to the facility to conclude the investigation into the allegation listed above. LPA met with Administrator, Shakilla Williams who was informed of the purpose of the visit.

Regarding the allegation, “Staff yell at clients” it was reported Staff 1 (S1) yelled at Client 1 (C1) to “get out of the room” and additional staff had to intervene and separate S1 from C1. Witness interviews reported on the date of the incident, S1 was assigned to supervise C1, and C1 became agitated with another client, resulting in S1 intervening by asking C1 to calm down. Interviews reported C1 made a disrespectful statement to S1 regarding S1’s personal life, and S1 was observed to be visibly offended by the comment and upset, and responded by yelling at C1 to leave their assigned activity room. C1 confirmed S1 yelled at them. As a result, the allegation is Substantiated.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Janette Romero
LICENSING EVALUATOR SIGNATURE:

DATE: 03/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/25/2024
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 6
Control Number 18-AS-20230810155706
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: 03/25/2024
NARRATIVE
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Regarding the allegation that, “Staff do not follow resident care plans” it was reported Staff 2 (S2) provides extra food for Client 2 (C2) resulting in aggressive behavior episodes. LPA reviewed the facility’s program design. Per the facility’s activity schedule, clients are provided one daily snack. S2 reported they have provided C2 with extra food to calm them down during a behavior episode. Per the program design, some of the behavior support techniques used by the facility are positive reinforcement of appropriate behaviors, response cost contingencies in which stimuli and rewards are removed and remain contingent upon behaviors and reinforcing coping skills by venting anger or frustration in a more appropriate way. The program design states the facility uses modeling prompts, praise, and verbal reinforcement to manage aggressive behaviors. Therefore, if C1 expressed a behavior episode or frustration, providing them with extra snacks to calm them down would contradict the facility’s behavior support techniques and interventions noted above. As a result, the allegation is Substantiated.

Regarding the allegation, “Staff did not ensure clients were supervised appropriately” it was reported S2 left Client 3 (C3) unsupervised resulting in C3 getting out of their wheelchair and removing their clothes. S2 reported leaving C3 with Staff 3 (S3) for a moment as S2 assisted another client to the restroom. LPA was unable to corroborate S3 was asked to supervise C3. S2 stated they returned to find C3 down the hall, alone and without a top and undergarment. LPA reviewed C3’s Individual Program Plan, which notes that C3 requires constant supervision during waking hours to prevent injury/harm in all settings/situations as they do not possess or exercise appropriate safety awareness. LPA reviewed the facility’s program design, which states the staffing schedule is based on a 1:3 staff-to-client ratio. As a result, the allegation is Substantiated.



Regarding the allegation, “Clients not accorded dignity in relationships with staff” it was alleged that Client 4 (C4) had blood dripping down their leg and S1 disclosed details of C4’s personal health information with other facility staff in the presence of clients rather than providing immediate assistance. Information obtained from interviews and S1 corroborated the allegation and added that S1 used hand gestures to point at C4’s genital area. Based on interviews conducted, the allegation is Substantiated.
SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Janette Romero
LICENSING EVALUATOR SIGNATURE:

DATE: 03/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/25/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 18-AS-20230810155706
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: 03/25/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/04/2024
Section Cited
CCR
82072(a)(3)
1
2
3
4
5
6
7
 (a)Each client shall have personal rights... (3) To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation... This requirement was not met as evidenced by:
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7
Licensee stated the facility conducted a staff training regarding clients' personal rights on 2/9/2024. LPA reviewed the training sign-in sheet signed by employees.
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14
During investigation of the complaint, LPA found that S1 yelled at C1 during one occasion. This poses a potential safety risk to clients in care.
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14
Type B
04/04/2024
Section Cited
CCR
82022(h)
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7
(h) The day program shall operate in accordance with the terms specified in the plan of operation and may be cited for not doing so. This requirement was not met as evidenced by:
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7
Licensee stated the facility will conducted a staff training regarding the facility's program design. Licensee stated they will provide LPA with a copy of training sign-in sheet signed by employees by POC due date.
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LPA found that S2 provides extra food for C2 during behavior episodes to calm them down, which contradicts the facility's program design. This poses a potential health risk for clients in care.
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9
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14
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: Tricia Danielson
LICENSING EVALUATOR NAME: Janette Romero
LICENSING EVALUATOR SIGNATURE:

DATE: 03/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/25/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 18-AS-20230810155706
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: 03/25/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/04/2024
Section Cited
CCR
82078(a)
1
2
3
4
5
6
7
(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:
1
2
3
4
5
6
7
Licensee stated the facility conducted a staff training regarding clients' personal rights on 2/14/2024. LPA reviewed the training sign-in sheet signed by employees.
8
9
10
11
12
13
14
LPA found S2 left C3 unsupervised and C3 and got out of their wheelchair and removed their undergarment clothes. This poses a potential safety risk to clients in care.
8
9
10
11
12
13
14
Type B
04/04/2024
Section Cited
CCR
82072(a)(1)
1
2
3
4
5
6
7
(a) Each client shall have personal rights... (1) To be accorded dignity in his/her personal relationships with staff and other persons. This requirement was not met as evidenced by:
1
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3
4
5
6
7
Licensee stated the facility conducted a staff training regarding clients' personal rights on 2/14/2024. LPA reviewed the training sign-in sheet signed by employees.
8
9
10
11
12
13
14
LPA found that S1 disclosed C4's personal health information with other facility staff in the presence of clients rather than providing immediate assistance. This poses a potential safety/health risk to clients in care.
8
9
10
11
12
13
14
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: Tricia Danielson
LICENSING EVALUATOR NAME: Janette Romero
LICENSING EVALUATOR SIGNATURE:

DATE: 03/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/25/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 6
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
08/10/2023 and conducted by Evaluator Janette Romero
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20230810155706

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: 20DATE:
03/25/2024
UNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Administrator, Shakilla WilliamsTIME COMPLETED:
02:15 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff accepted a client with symptoms of illness into the day program
Staff speak inappropriately to clients
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 3/25/2024, Licensing Program Analyst (LPA) Janette Romero arrived unannounced to the facility to conclude the investigation into the allegations listed above. LPA met with Administrator, Shakilla Williams who was informed of the purpose of the visit.

Regarding the allegation, “Staff accepted a client with symptoms of illness into the day program” it was reported Staff 1 (S1) allowed Client 1 (C1) to enter the facility while having a fever. LPA reviewed the facility’s Covid-19 Participant Screening log for August 2023, which documented clients’ body temperatures upon arrival to day program. The logs noted that participants with a body temperature of 100.4 degrees Fahrenheit (F) or higher will not be transported to day program.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Janette Romero
LICENSING EVALUATOR SIGNATURE:

DATE: 03/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/25/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 18-AS-20230810155706
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: 03/25/2024
NARRATIVE
1
2
3
4
5
6
7
8
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12
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The Covid-19 logs for August 2023 did not document C1 having a body temperature of 100.4 degrees F or higher. C1’s board and care facility stated C1 did not display symptoms of illness and did not have a fever during the month of August of 2023. Interviews with day program staff reported transportation drivers are instructed to not transport clients that display symptoms of illness. Based on interviews conducted and record review, the allegation is Unsubstantiated.

Regarding the allegation, “Staff speak inappropriately to clients” it was alleged Staff 2 (S2) repeats the noises clients make and laughs with Staff 3 (S3). S2 reported they teach clients new noises and repeat the noises together with the clients, which makes the clients laugh. S2 stated the noises are not repeated with malicious intent. S2 denied repeating the noises and laughing with S3. Additional interviews, including an interview with S3 corroborated the information provided by S2. Based on interviews conducted, the allegation is Unsubstantiated.
SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Janette Romero
LICENSING EVALUATOR SIGNATURE:

DATE: 03/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/25/2024
LIC9099 (FAS) - (06/04)
Page: 6 of 6