342701176-10-10-2024-27-AS-KHOS-DA4UMS-20241016154250

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342701176
Report Date: 10/10/2024
Date Signed: 10/10/2024 11:39:58 AM

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
08/22/2024 and conducted by Evaluator Christina Valerio

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20240822091947

FACILITY NAME:	CISTERS LOVING CARE HOME II		FACILITY NUMBER:	342701176
ADMINISTRATOR:	FUENTES, FLORINDA		FACILITY TYPE:	735
ADDRESS:	5316 NECTAR CIRCLE		TELEPHONE:	(916) 897-3834
CITY:	ELK GROVE	STATE: CA	ZIP CODE:	95757
CAPACITY:	4	CENSUS: 4	DATE:	10/10/2024
		UNANNOUNCED	TIME BEGAN:	08:20 AM
MET WITH:	Florinda Fuentes		TIME COMPLETED:	11:50 AM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff hit resident.
Staff restrained resident.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Christina Valerio arrived unannounced to conduct a complaint investigation and deliver complaint findings. LPA met with Administrator Florinda Fuentes, and explained the purpose of the visit.

According to the Reporting Party (RP), RP was informed that Staff 4 (S4) hit Resident 1 (R1) with a stick the stomach and Staff 1 (S1) had restrained R1 on 08/21/24.

On 10/10/2024, LPA Valerio reviewed facility records. Facility records show a Special Incident Report (SIR) submitted on 08/21/2024 regarding an incident with Resident 1 (R1) and facility staff. R1 was engaging in behaviors from 08/21/2024 at 2:00 AM until the following day, 08/22/24. During this time, R1 was agitated and tired. Staff 2 (S2) and Staff 4 (S4) attempted to use de-escalation techniques to calm R1 down on 08/21/2024 at 2:00 AM until R1 left for day program. R1 was observed to hit walls in the room, punch garbage cans, hit staff using R1's hands, and hit staff with a chair.
Continues on LIC 9099 - C...

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE:	DATE: 10/10/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2024

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-20240822091947

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: CISTERS LOVING CARE HOME II	FACILITY NUMBER: 342701176
	VISIT DATE: 10/10/2024

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

Continues from LIC 9099

After coming home from day program, R1 became agitated and started behaving aggressively towards staff. A total of seven (7) staff were involved to assist the situation, including the house behaviorist. Police were contacted and arrived hours later. R1 was transported to the hospital and returned the same day. Based on the SIR, the staff involved did not touch R1 at any point during the crisis.

On 08/29/2024, LPA Valerio interviewed R1. R1 reported that staff treat R1 good, replied no when asked if any staff ever hit R1, and replied no when asked if staff ever physically touched R1. R1 stated R1 remembered the day on 08/21/24. R1 reported R1 slept all day. R1 did not report any negative emotions towards any of the staff.

LPA Valerio interviewed Staff 1, Staff 2, Staff 3, and Staff 4. Based on staff interviews, interviewed corroborate details explained the SIR for 08/21/2024. S1 stated that S1 does not believe that S4 hurt R1. However, S4 was suspended until the investigation was complete. S2 was present during the incident. S2 reported that S4 did not hit R1. R1 hit S4. S3 reported working on 08/22/2024. S3 stated no restraints were used on R1 during the incident. S3 did not hear or observe that S4 hit R1.

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, no deficiencies cited. Exit interview was held and a copy of report was left at the facility.

SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE:	DATE: 10/10/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 2