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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700829
Report Date: 07/19/2022
Date Signed: 07/19/2022 01:47:27 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, 520 COHASSET RD., STE. 170
CHICO, CA 95926
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/19/2022 and conducted by Evaluator Sarena Keosavang
PUBLIC
COMPLAINT CONTROL NUMBER: 25-AS-20220519163710
FACILITY NAME:KALA HOUSEFACILITY NUMBER:
342700829
ADMINISTRATOR:SHOAAXUM JOHNSONFACILITY TYPE:
738
ADDRESS:6804 SANTA JUANITA AVETELEPHONE:
(916) 216-8680
CITY:ORANGEVALESTATE: CAZIP CODE:
95662
CAPACITY:4CENSUS: 4DATE:
07/19/2022
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Michael Christopher- Lead DSPTIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Resident was injured by staff during a physical altercation.
INVESTIGATION FINDINGS:
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On 07/19/2022, Licensing Program Analyst (LPA) Sarena Keosavang was in contact and met with Lead DSP, Michael Christopher. Complaint allegation is Personal Rights in that it was reported that a resident was injured by a staff person during a physical altercation.

LPA Keosavang completed the required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID 19 infection to affirm no COVID-19 related symptoms. The administrator/staff person was contacted to complete a facility risk assessment. LPA Gurriere ensured that hand sanitizer was applied before entering the facility and the following Personal Protective Equipment (PPE) was worn: N-95 mask. Additionally, LPA was screened by a staff person upon entering the facility.

Continue on page LIC 9000-C.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Sarena Keosavang
LICENSING EVALUATOR SIGNATURE:

DATE: 07/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2022
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 25-AS-20220519163710
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME: KALA HOUSE
FACILITY NUMBER: 342700829
VISIT DATE: 07/19/2022
NARRATIVE
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During the investigative process, the administrator, five staff persons and the resident were interviewed. Several documents were obtained for review and included the Roster of Facility Residents, a listing of staff persons present during the incident, the Resident’s Physician’s Report and the Resident’s Individual Program Plan (IPP).

During the month of May 2022, it was reported that there was an incident that occurred between a staff person and a resident. It was stated that the resident was having a behavioral issue and started throwing rocks indoors at the staff person. The staff person put up his arms in a defensive manner to try to block the rocks that were being thrown at him. The resident collided with the staff person and the resident fell to the floor, continuing to kick and scratch at the staff person. The staff person did not fall; however, sustained bleeding scratch marks to the neck. The resident asked to be taken to the Emergency Room (ER) and it was reported that the resident did not have any type of laceration, but rather sustained an abrasion to the back of his head. The ER did not need to provide treatment for any type of head wound as the laceration was not considered significant.

Although the allegation may have happened, or is valid, there is not a preponderance of evidence to prove that the alleged violation(s) occurred; therefore, the allegation findings are Unsubstantiated.

Exit interview conducted.
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Sarena Keosavang
LICENSING EVALUATOR SIGNATURE:

DATE: 07/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2