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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700829
Report Date: 04/07/2023
Date Signed: 04/07/2023 01:16:28 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 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
07/01/2022 and conducted by Evaluator Cassie Yang
COMPLAINT CONTROL NUMBER: 25-AS-20220701164236
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: 3DATE:
04/07/2023
UNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Michael AlvarezTIME COMPLETED:
12:10 PM
ALLEGATION(S):
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Staff twisted resident's chest area.
Staff handled resident in a rough manner.
Staff sprayed resident's face with water.
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Cassie Yang and Ivan Avila arrived at the facility to deliver the findings of the allegations cited above. LPA met with direct support professional, and explained the purpose of the visit.

During this investigation, LPA's conducted extensive interviews and finds the facility to have not met Tittle 22 requirements.

A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. The following deficiency was cited as per Title 22 Regulations and the Health and Safety Code.


Please continue on LIC 9099-C...
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Cassie Yang
LICENSING EVALUATOR SIGNATURE:

DATE: 04/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2023
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 25-AS-20220701164236
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833
FACILITY NAME: KALA HOUSE
FACILITY NUMBER: 342700829
VISIT DATE: 04/07/2023
NARRATIVE
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Allegation: Staff twisted resident's chest area.
The Department conducted interviews to investigate this allegation. During interview conducted with an eye witness (S3) on 8/22/2022, S2 informed LPA she remembered vividly of suspected abuser (S2) to twist client's (C1) chest area aggressively. S3 informed LPA that she was unable to stop S2 and was afraid to leave for help, leaving C1 in the bathroom alone with S2. Facility failed to ensure clients in care are to be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse, or other actions of a punitive nature, including but not limited to: interference with the daily living functions, including eating, sleeping, or toileting; or withholding of shelter, clothing, medication or aids to physical functioning, therefore, the allegation is SUBSTANTIATED.

Allegation Staff handled resident in a rough manner.
The Department conducted interviews to investigate this allegation. During interview conducted with S3 on 8/22/2022, S3 informed LPA that C1 was trying to leave the shower. S3 stated S2 was frustrated and forced C1 back into the shower. S3 informed LPA she was afraid that C1 would slip in the shower as the floor was wet since the water was turned on. S3 informed LPA she told S2 that he cannot do that as it is against C1's personal rights. Therefore, the allegation is SUBSTANTIATED.

Allegation: Staff sprayed resident's face with water.
The Department conducted interviews to investigate this allegation. During interview conducted with S3 on 8/22/2022, S3 informed LPA when she attempted to stop S2 from forcibly showering C1 by reaching for the shower head in S2's hands, S2 raised his arm up higher to prevent S3 from grabbing it. S3 stated the shower head was spraying in C1's face during this process. Therefore, the allegation is SUBSTANTIATED.

As a result of this investigation, deficiency was cited. Please see LIC 9099-D.

Exit interview conducted. A copy of the report and appeals rights provided.

SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Cassie Yang
LICENSING EVALUATOR SIGNATURE:

DATE: 04/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 25-AS-20220701164236
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: KALA HOUSE
FACILITY NUMBER: 342700829
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/07/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
04/10/2023
Section Cited
CCR
80072(a)(3)
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80072(a)(3) Personal Rights- Each client shall have personal rights which include, but are not limited to, the following: To be free from corporal or unusual punishment, infliction of pain, humiliation, ridicule...or other actions of a punitive nature. This requirement is not met as evidenced by:
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S2 was immediately removed from schedule and then terminated in July 2022.
Licensee is to provide training for all direct care and administrative staff on the personal right of clients to be free from corporal punishment.
Licensee will schedule the training and provide CCL with signed staff attendance sheet as proof of correction.
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Based on interviews conducted, licensee failed to ensure one of four clients (C1) was free from corporal or unusual punishment, infliction of pain, humiliation when C1's chest area was twisted by S2, when S2 twisted C1's chest area, shoving S2 back into the shower and spraying water on C1's face. This poses an immediate risk to clients 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: Anthony Perez
LICENSING EVALUATOR NAME: Cassie Yang
LICENSING EVALUATOR SIGNATURE:

DATE: 04/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2023
LIC9099 (FAS) - (06/04)
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