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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 360909246
Report Date: 06/14/2022
Date Signed: 11/16/2022 01:38:23 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, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/12/2022 and conducted by Evaluator Rayshaun Nickolas
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20220512142938
FACILITY NAME:PADUA VILLAGE, INC.FACILITY NUMBER:
360909246
ADMINISTRATOR:KIMBERLY ROWEFACILITY TYPE:
735
ADDRESS:11981 MIDWAY RD.TELEPHONE:
(760) 248-6245
CITY:LUCERNE VALLEYSTATE: CAZIP CODE:
92356
CAPACITY:26CENSUS: 21DATE:
06/14/2022
UNANNOUNCEDTIME BEGAN:
01:52 PM
MET WITH:Shawn Barracks, Program Director
Kimberly Wilson, Assistant Administrator		TIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Staff hit resident
Staff speaks inappropriately to resident
Staff confines resident to a couch
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Rayshaun Nickolas conducted an unannounced visit to the facility to conclude a complaint investigation regarding the listed allegations. LPA met with Program Director Shawn Barracks. LPA explained the purpose of the visit.

The investigation consisted of LPA interviews with four (4) staff and eight (8) clients. LPA also reviewed facility file documents pertinent to the investigation.

Allegation #1 “staff hit resident". LPA Interviewed eight (8) clients, and all clients denied witnessing facility staff hitting any clients. LPA interviewed four (4) staff, persons. One (1) of the staff interviewed stated they witnessed Staff #1 (S1) hit Client #2 (C2). It was reported that S3 witnessed S1 slap C2’s hand and tell C2 Don’t Hit Me. LPA attempted to interview C2, but the client is non-verbal and uses their hands as a form of expression.

Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Rayshaun Nickolas
LICENSING EVALUATOR SIGNATURE:

DATE: 06/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2022
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 3
Control Number 56-AS-20220512142938
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME: PADUA VILLAGE, INC.
FACILITY NUMBER: 360909246
VISIT DATE: 06/14/2022
NARRATIVE
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Allegation #2 “Staff speaks inappropriately to the resident”. LPA interviewed eight (8) clients, and all clients denied witnessing any facility staff speaking inappropriately to a client. LPA interviewed four (4) staff persons, and S4 stated that they witnessed S5 speaking inappropriately to C1. LPA was informed by the witness that S5 regularly yells or makes derogatory remarks toward C1. Interviews with clients revealed that no clients have witnessed “Staff speaks inappropriately to the resident”.

Allegation #3 “Staff confines resident to a couch”. LPA interviewed four (4) staff persons. Two (2) staff members reported that they witnessed S1 confine C2 to a couch. It was reported that S3 witnessed S1 sitting so close to C2 that their knees were touching. It was reported that S3 witnessed C3 attempting to get off the couch, and S1 prevented the client from moving”. It was further reported that S4 witnessed C2 getting off the couch and walking to the sliding glass door. S2 went to C2 and took the client back to the couch and pushed the client down on the couch as S1 stood at the sliding glass door watching. Interviews conducted with clients revealed that none of the clients witnessed the allegation "Staff confines resident to a couch”.

Based on interviews conducted, the above allegations are Substantiated. A finding that the complaint is SUBSTANTIATED means that the allegation(s) is valid because the preponderance of the evidence standard has been met. California Code of Regulations (CCR), Title 22, Division 6 is cited on the attached LIC 9099D

An exit interview was conducted with Barracks and Wilson and a copy of this report was provided along with Appeal Rights.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Rayshaun Nickolas
LICENSING EVALUATOR SIGNATURE:

DATE: 06/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 56-AS-20220512142938
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: PADUA VILLAGE, INC.
FACILITY NUMBER: 360909246
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/14/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type B
07/14/2022
Section Cited
CCR
80072(a)(3)
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80072(a) (3) Personal Rights- Personal Rights Except for children’s residential facilities, each client shall have personal rights which include, but are not limited to, the following...

This requirement was not met as evidenced by:
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Licensee/Administrator shall read the entire section of the CCR, Title 22, Division 6, section 80072, and submit in writing that they read and understand personal rights.
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Based on LPA interviews and record review, the Licensee did not ensure C1 was free from verbal abuse. Licensee also did not ensure C2 was free from physical abuse and restraint by S1 and S2. This poses an potential threat to clients' health, safety, and personal rights in care.
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Licensee/Administrator shall also provide training to all staff and submit proof of training with staff signatures to LPA on July 14, 2022, by business closure.
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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: Karen Clemons
LICENSING EVALUATOR NAME: Rayshaun Nickolas
LICENSING EVALUATOR SIGNATURE:

DATE: 06/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3