<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700677
Report Date: 04/30/2025
Date Signed: 04/30/2025 04:14:05 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/11/2025 and conducted by Evaluator Arvin Villanueva
COMPLAINT CONTROL NUMBER: 27-AS-20250311152214
FACILITY NAME:MISSION HOME CBN INCFACILITY NUMBER:
342700677
ADMINISTRATOR:ORLANDO CARPIOFACILITY TYPE:
735
ADDRESS:8591 MISSION FALLS CIRCLETELEPHONE:
(916) 519-7474
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY:4CENSUS: 4DATE:
04/30/2025
UNANNOUNCEDTIME BEGAN:
03:24 PM
MET WITH:Rona Agoncilio, Staff on dutyTIME COMPLETED:
04:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff are unable to meet the needs of the client while in care.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 4/30/2025, Licensing Program Analyst Arvin Villanueva (LPA) arrived at this facility to conduct a follow-up complaint visit and deliver findings regarding the allegation noted above. LPA met with staff on duty, Rona Agoncillio, and stated the purpose of this visit. The administrator, Orlando Carpio, was notified and permitted staff to sign this report. Today's visit there were 4 clients in care with 3 staff on duty.
The investigation into the above allegation consisted of interviews with facility staff and outside agency staff. Additionally, review of relevant records including staff training and records relating to Resident_1(R1) was also conducted.
Interview with the Administrator (AD) revealed that R1 has extensive behavioral needs that the facility could no longer provide and confirmed a 60-day eviction notice was served in July 2024. AD stated that R1 remains in the home pending new placement. AD stated that the facility continues to attempt to meet R1’s needs through behavioral consultations, one-on-one staffing, crisis intervention services, and day program referrals. AD stated that R1 had declined or refused to engaged in some of these services. AD also reported that R1 has an open court case due to previous assaults and property destruction.
{1 of 3}
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Arvin Villanueva
LICENSING EVALUATOR SIGNATURE:

DATE: 04/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/30/2025
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 27-AS-20250311152214
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: MISSION HOME CBN INC
FACILITY NUMBER: 342700677
VISIT DATE: 04/30/2025
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Interview with facility staff (S1 and S2) revealed that R1 is isolative and unpredictable. They confirmed training on behavioral interventions and noted R1’s refusal to participate in day program or redirection.

Interview with R1’s Service Coordinator (SC) from Alta California Regional Center (ACRC) confirmed that R1 exhibits extensive and challenging behaviors, including frequent psychiatric hold (5150), police involvement, physical aggression, refusal of hygiene, and property destruction. SC stated that the current facility is a level 6 home (formerly level 4i) and is equipped to manage high-level behavioral needs. SC stated that home staff have made efforts to redirect R1 and protect other individuals in the home during R1’s behavioral incidents. SC stated that ACRC is actively trying to secure an alternative placement for R1 due to the increased of behavioral issues. SC explained that since the issuance of the 60-day eviction notice, ACRC seek multiple placement options, but none have accepted R1 for admission to date. SC noted that one potential placement, a crisis home, is currently pending vendorization and licensure. In the meantime, R1 remains at the current facility.

Record review of R1’s eviction notice dated 9/19/2024 revealed that R1 had posed imminent danger to self and others at the facility due to R1’s behavioral issues. The notice also documents several Individual Program Plan (IPP) meetings and behavioral intervention strategies were attempted and implemented.

Record review of R1’s intervention plan documents repeated instances of non-compliance, inappropriate elimination of feces and urine, and aggression. In the document that staff use to track R1’s behaviors on a daily basis, from March 1, 2025 to March 13, 2025 alone, R1 exhibited 25 instances of verbal conflict, 15 instances of physical aggression, and 3 instances of urination in inappropriate areas and 6 incidents of property destruction.

Record review of staff training documents from 2022 to 2024 reveals an ongoing effort to ensure that staff have the skills needed to meet the needs of clients. Since February 2022, staff have participated in various training sessions to improve their ability to manage aggressive behaviors and stay updated on residents’ needs. These sessions included topics like Managing Aggressive Behaviors and Resident Updates (2/20/22), and specialized training for individuals with developmental disabilities, such as Caring for Adults with Developmental Disabilities (3/24/22) and Behavior Intervention Plans (4/1/22). In 2022 and 2023, staff continued to receive training on behavior management and intervention strategies, including Positive Intervention Strategies and Behavior Management. In 2024, additional training focused on Functional Equivalent Replacement Behavior and Managing Assaultive and Aggressive Behaviors.


{2 of 3}
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Arvin Villanueva
LICENSING EVALUATOR SIGNATURE:

DATE: 04/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/30/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 27-AS-20250311152214
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: MISSION HOME CBN INC
FACILITY NUMBER: 342700677
VISIT DATE: 04/30/2025
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Although AD stated the facility can no longer provide the care R1 needs - referring to the limitations of their capacity to address R1’s increasing behavioral issues - the facility staff have taken appropriate and proactive measures, including a 60-day eviction notice, coordinating with ACRC and other agencies to find appropriate placement that can meet R1’s needs, and implementing needed supports and programs while R1 remains at the home until new placement is secured.

Based on the information obtained during the investigation, including interviews, documentation and record reviews, there is not a preponderance of evidence to support the allegation that staff are unable to meet the needs of R1. Therefore, this allegation was UNSUBSTANTIATED.

A finding that is unsubstantiated means that 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.

Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 6, no deficiencies cited.

Exit interview was conducted and a copy of this report and appeal rights were provided.

SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Arvin Villanueva
LICENSING EVALUATOR SIGNATURE:

DATE: 04/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/30/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3