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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700185
Report Date: 01/07/2022
Date Signed: 01/07/2022 02:03:19 PM

Unsubstantiated


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
12/10/2021 and conducted by Evaluator Michael Bilger
COMPLAINT CONTROL NUMBER: 27-AS-20211210155939
FACILITY NAME:CUPINO HOMEFACILITY NUMBER:
342700185
ADMINISTRATOR:CUPINO, RAULFACILITY TYPE:
735
ADDRESS:8636 LILYPAD LANETELEPHONE:
(916) 509-9450
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY:4CENSUS: 4DATE:
01/07/2022
UNANNOUNCEDTIME BEGAN:
12:44 PM
MET WITH:Monica ButayTIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Staff inappropriately restrain residents
Staff handle residents in a rough manner
INVESTIGATION FINDINGS:
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On 1-7-22, at 12:44pm Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to deliver complaint findings for the allegations listed above. LPA met with assistant administrator Monica Butay and explained the purpose of the visit. Administrator was notified and gave permission for Monica to accommodate LPA and sign in his absence. During the course of this investigation, LPA interviewed five staff members, Assistant Administrator, and four clients in care. LPA also reviewed Individualized Program Plan (IPP) for resident1 (R1), staffing schedule, charting notes, and incident report dated 12-11-21. LPA also reviewed police report dated 12-13-21 and interviewed regional center case worker. LPA also conducted facility observation of staff interaction with clients on 12-22-21.
Based on interviews, record reviews, and observation it is determined that an incident occurred on 12-11-21 in which R1 became upset and exited facility with staff accompaniment. It was further revealed through interviews that R1 was redirected back to the facility. Additional interviews with staff and clients revealed that there have been no witnessed episodes of restraints or rough handling performed at the facility. Review of police report welfare check dated 12-13-21 did not indicate a restraint was placed on R1. {Cont on 9099C}
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE:

DATE: 01/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/07/2022
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 2
Control Number 27-AS-20211210155939
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: CUPINO HOME
FACILITY NUMBER: 342700185
VISIT DATE: 01/07/2022
NARRATIVE
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Facility observation by LPA on 12-22-21 did not reveal any rough handling or restraints observed.

Based on interviews, record reviews, and observation it is determined that the above allegations are UNSUBSTANTIATED. An exit interview was conducted with Monica Butay and a copy of this report was left with Monica.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE:

DATE: 01/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/07/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2