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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 347005345
Report Date: 06/19/2021
Date Signed: 06/19/2021 01:51:08 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
09/15/2020 and conducted by Evaluator Albert Johnson
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20200915102341
FACILITY NAME:PEER HOME 2FACILITY NUMBER:
347005345
ADMINISTRATOR:ANTONIO "TANYA" BERNADASFACILITY TYPE:
735
ADDRESS:7727 MASTERS STREETTELEPHONE:
(916) 509-9450
CITY:ELK GROVESTATE: CAZIP CODE:
95758
CAPACITY:4CENSUS: 4DATE:
06/19/2021
UNANNOUNCEDTIME BEGAN:
11:33 AM
MET WITH:Antonio Tanya BernadasTIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Staff allegedly verbal abused client
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Albert Johnson arrived and met with ANTONIO "TANYA" BERNADAS to deliver investigation findings.

Based on records reviewed and interviews conducted, the Staff verbally abused R1.
S1 denied saying the alleged language and stated that he was upset, because R1 touched his personal items including the food he brought in from Panda express.

S1 stated that he was angry and let R1 know that she should not be touching his personal items. S1 admitted that he shouted at R1 but again denied using derogatory language toward R1.

Continued
Substantiated
Estimated Days of Completion: 0
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE:

DATE: 06/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2021
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-20200915102341
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: PEER HOME 2
FACILITY NUMBER: 347005345
VISIT DATE: 06/19/2021
NARRATIVE
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LPA confirmed with another staff (S2) going off shift that there was an argument between S1 and R1, but did not hear the words used or the reason for the argument, he was able to intervene and settle the situation before he left for the evening.

As a result of this investigation, LPA finds allegation to be (S) Substantiated - 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 deficiencies were cited on 9099-D, per Title 22 Regulations, Division 6.

Exit interview was conducted with Administrator.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE:

DATE: 06/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 3
Control Number 27-AS-20200915102341
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: PEER HOME 2
FACILITY NUMBER: 347005345
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/19/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/21/2021
Section Cited
CCR
80072(a)(3)
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Personal Rights. Each client has the right 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,
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Administrator will hold a meeting/ inservice with staff discussing the personal rights of residents.. Facility will send a sign in sheet and written protocol/ agenda for the in-service by Monday 06/21/21.
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 or toileting; or withholding of shelter, clothing, medication or aids to physical functioning. This requirement was not met as evidenced by-S1 admitted to being was verbally aggressive to R1. This posed an immediate threat to resident 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: Stephenie Doub
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE:

DATE: 06/19/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 3