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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 347004469
Report Date: 10/27/2021
Date Signed: 10/27/2021 01:33:13 PM

Substantiated


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
08/10/2021 and conducted by Evaluator Christina Valerio
COMPLAINT CONTROL NUMBER: 27-AS-20210810152251
FACILITY NAME:KUNZITE RESIDENTIAL INC.FACILITY NUMBER:
347004469
ADMINISTRATOR:ABRIAM, ZENAIDAFACILITY TYPE:
735
ADDRESS:9646 KUNZITE COURTTELEPHONE:
(916) 897-8801
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY:6CENSUS: 6DATE:
10/27/2021
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Zenadia AbriamTIME COMPLETED:
11:00 AM
ALLEGATION(S):
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Client was slapped in face and hand while on an outing at park
Personnel did not provide for the care and safety of persons without physical or verbal abuse towards clients
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) C. Valerio arrived at the facility unannounced to deliver complaint investigation findings. LPA Valerio explained the purpose of the visit to Administrator Zenadia. facility staff confirmed no residents or staff have displayed any signs or symptoms of COVID in the last 10 days.

The Department has determined the following as it relates to the allegations: Client was slapped in face and hand while on an outing at park and Personnel did not provide for the care and safety of persons without physical or verbal abuse towards clients.

LPA Valerio reviewed video footage recorded on 08/10/2021. Video footage revealed Kunzite staff and Kunzite residents were at Derr-Okimoto Park on the morning of 08/10/2021. Kunzite staff and residents were observed sitting at picnic tables. Three staff were observed: Staff 1 (S1) was wearing a red and black checkered shirt, Staff 2 (S2) was wearing a pink shirt, and Staff 3 (S3) was wearing a black and white checkered shirt.
Continues on LIC 9099-C...
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE:

DATE: 10/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2021
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-20210810152251
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: KUNZITE RESIDENTIAL INC.
FACILITY NUMBER: 347004469
VISIT DATE: 10/27/2021
NARRATIVE
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...Continued from LIC 9099

LPA Valerio obtained photo copies of identification cards for all Kunzite staff. LPA Valerio showed identification cards to a witness. The witness pointed out the staff member who was seen slapping resident 1 (R1) on the face and hand. The witness confirmed a second time that S1 was the individual to hit R1. A statement was provided to LPA Valerio.

LPA Valerio observed interactions with staff and residents on two separate occasions. No health or safety concerns observed during the visits. LPA Valerio attempted to interview R1. Due to communication barriers, R1 did not confirm or deny anything had happen to R1 by staff. R1 did not have bruising on face or hand; however, it was observed that R1 had a bruise on R1's left arm near the distal humerus portion of the body.

LPA Valerio interviewed four staff members (S1 - S4). All staff denied any staff member violating personal rights of any residents and denied ever witnessing staff being aggressive or physical with a resident. LPA asked staff what clothes they were wearing to the park. S1 reported wearing a grey scrub shirt with cancer ribbons. S2 reported wearing a pink shirt with dark blue pants. S3 reported wearing a black and white checkered shirt. S4 was not present during the outing.

Based on the witness statement, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8) are being cited on the attached LIC-9099D. Failure to correct the deficiency may result in civil penalties. Appeal rights were provided.

An immediate $500 penalty is being issued today. At the time of the conclusion of this complaint investigation, the issuance of a Civil Penalty was still being determined. However, the Licensee was informed that a Civil Penalty may be assessed based on Health & Safety Code section 1569.49 (1).
 
An exit interview was conducted, and a copy of the report was provided to Administrator Zenadia Abriam.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE:

DATE: 10/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 3
Control Number 27-AS-20210810152251
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: KUNZITE RESIDENTIAL INC.
FACILITY NUMBER: 347004469
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/27/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/28/2021
Section Cited
CCR
80072(a)(3)
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80072 Personal Rights (a)...each client shall have personal rights.. the following: (3)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... This requirement was not met as evidenced by:
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The licensee stated S1 is no longer associated with any licensed facility owned by licensee. The licensee will send an updated LIC 500 by POC due date.
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Based on observations, the licensee did not ensure 1 out of 6 residents were kept free from unusual punishment, infliction of pain, or other actions of a punitive nature, which resulted in R1 being slapped in the face and on the hand by S1. This poses an immediate health and safety risk to persons in care.
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Type A
10/28/2021
Section Cited
CCR
80072(a)(1)
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80072 Personal Rights (a)...each client shall have personal rights which include...the following: (1) To be accorded dignity in his/her personal relationships with staff and other persons. This requirement was not met as evidenced by:
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The licensee stated in-service training related to personal rights,abuse, and boundaries will be provided to staff as a refresher. The licensee will send a sign-in sheet with all staff signatures by POC due date.
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Based on observation, the licensee did not ensure 1 out of 4 staff members maintained professional boundaries with 1 out of 6 residents. S1 did not accord dignitiy in S1's personal relationship with R1, which poses an immediate health and safety risk to persons 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: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE:

DATE: 10/27/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 3