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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700065
Report Date: 08/08/2022
Date Signed: 08/08/2022 10:33:55 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/18/2022 and conducted by Evaluator Christina Valerio
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20220318154056
FACILITY NAME:WILTON STABLESFACILITY NUMBER:
342700065
ADMINISTRATOR:TANYA BARRETOFACILITY TYPE:
735
ADDRESS:11119 MANN ROADTELEPHONE:
(916) 687-4548
CITY:WILTONSTATE: CAZIP CODE:
95693
CAPACITY:4CENSUS: 2DATE:
08/08/2022
UNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Shakira WatsonTIME COMPLETED:
10:40 AM
ALLEGATION(S):
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Resident was in a physical altercation with another resident
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Christina Valerio arrived unannounced to deliver investigation findings. LPA met with facility staff and explained the purpose of the visit. Staff called Administrator Tanya and approved staff to sign. Staff confirmed 0 residents and 0 staff have displayed any signs or symptoms of COVID in the last 10 days.

The department has concluded the following as it relates to the allegation: resident was in a physical altercation with another resident

According to record review, staff interviews, and resident interviews, a physical altercation occurred with Resident 1 (R1) and Resident 2 (R2) during evening shift. R1 initiated the first hit by using a closed fist to hit R2 in the face. R2 reacted by using a closed fist to hit R2.

Contines on LIC 9099 - C...
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE:

DATE: 08/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2022
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 7
Control Number 27-AS-20220318154056
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: WILTON STABLES
FACILITY NUMBER: 342700065
VISIT DATE: 08/08/2022
NARRATIVE
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Continued from LIC 9099

According to staff interviews, two staff (S1 and S2) observed R1 becoming agitated and went to take R1's aggression out on R2, whom was sitting in the television room. Staff stated R2 was hitting R1 in self-defense. Staff attempted to separate the two residents. R1 pushed a S1 against the wall and then went outside. The other staff member S2 went after R1 to calm R1 down while the other staff ensured R2 was not hurt. No injuries resulted from the altercation.

According to record review and interviews, responsible parties, regional center service coordinator, and Administrator were informed of the altercation.

Based on the above mentioned information, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations are being cited on the attached LIC-9099D. Failure to correct the deficiency may result in civil penalties. Appeal rights were provided.  An exit interview was conducted, and a copy of the report was provided to staff Shakira Watson.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE:

DATE: 08/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 27-AS-20220318154056
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: WILTON STABLES
FACILITY NUMBER: 342700065
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/08/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/09/2022
Section Cited
CCR
80072(a)(2)
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80072 Personal Rights (a) ...each client shall have personal rights which include, but are not limited to, the following: (2) To be accorded safe..

This requirement was not met as evidenced by:
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Licensee stated all staff will be reminded on policy and procedures in the event another altercation were to occur or how to prevent an altercation. Licensee to send plan to LPA Valerio by POC due date.
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Based on record review and interviews, 2 out of 4 residents were involved in a physical altercation, which poses an immediate health and safety risk to residents 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: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE:

DATE: 08/08/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 7
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/18/2022 and conducted by Evaluator Christina Valerio
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20220318154056

FACILITY NAME:WILTON STABLESFACILITY NUMBER:
342700065
ADMINISTRATOR:TANYA BARRETOFACILITY TYPE:
735
ADDRESS:11119 MANN ROADTELEPHONE:
(916) 687-4548
CITY:WILTONSTATE: CAZIP CODE:
95693
CAPACITY:4CENSUS: 2DATE:
08/08/2022
UNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Shakira WatsonTIME COMPLETED:
10:40 AM
ALLEGATION(S):
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Staff yells at resident
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Christina Valerio arrived unannounced to deliver investigation findings. LPA met with facility staff Shakira Watson and explained the purpose of the visit. Staff confirmed 0 residents and 0 staff have displayed any signs or symptoms of COVID in the last 10 days.

The department has concluded the following as it relates to the allegation: staff yells at resident

LPA Valerio interviewed 3 residents. According to R1, R1 states that staff yell at R1 as soon as R1 enters the home. R1 stated R1 noticed other residents were allowed to do things but R1 was restricted by staff. R1 stated when R1 would ask for a cigarette, staff would yell at R1 stating R1 lost his privilege. An interview with R2 showed that R2 does not feel that staff yell at R2. According to an interview with R3, staff are nice to R3.
Continues on LIC 9099-C...
This report was amended to change from confidential to public
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE:

DATE: 08/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 7
Control Number 27-AS-20220318154056
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: WILTON STABLES
FACILITY NUMBER: 342700065
VISIT DATE: 08/08/2022
NARRATIVE
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Continues from LIC 9099-A

LPA Valerio interviewed 3 staff members. According to all 3 staff, staff treat residents with respect and speak to the resident's in a calm tone. According to S3, there are times where staff need to redirect residents; however, the tone is not aggressive or rude.

LPA Valerio observed staff interactions with residents during in-person visits and telephone conversations. LPA Valerio did not observe staff yelling, speaking in a loud manner, or talking out of normal tone to residents. Residents were observe to have a calm and friendly demeanor around staff.

Based on all the information collected by the Department there is not a preponderance of evidence to prove the allegation occurred, therefore this allegation is UNSUBSTANTIATED.  Due to the above noted information, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, and therefore the allegations are unsubstantiated.

Per California Code of Regulations (CCRs) - Title 22, Division 6, no deficiencies cited.  Exit interview was held and a copy of report was given to facility staff Shakira Watson.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE:

DATE: 08/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 7