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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 360909246
Report Date: 10/20/2023
Date Signed: 10/20/2023 02:43:12 PM

Unsubstantiated


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
02/03/2023 and conducted by Evaluator Rayshaun Nickolas
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20230203160839
FACILITY NAME:PADUA VILLAGE, INC.FACILITY NUMBER:
360909246
ADMINISTRATOR:SHAWN F. BARRACKSFACILITY TYPE:
735
ADDRESS:11981 MIDWAY RD.TELEPHONE:
(760) 248-6245
CITY:LUCERNE VALLEYSTATE: CAZIP CODE:
92356
CAPACITY:26CENSUS: 24DATE:
10/20/2023
UNANNOUNCEDTIME BEGAN:
10:35 AM
MET WITH:Shawn Barracks, AdministratorTIME COMPLETED:
02:45 PM
ALLEGATION(S):
1
2
3
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5
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7
8
9
Staff are doing drugs while on the premises.
Staff are drinking while on the premises.
Facility is unkempt.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Rayshaun Nickolas arrived at the facility unannounced to deliver findings on the above allegations. LPA Nickolas met with administrator Shawn Barracks and explained the purpose of the visit. The investigation included facility tours, file reviews, and interviews with relevant parties.

Allegation #1 “Staff are doing drugs while on the premises”. The allegation alleged several facility staff members were doing drugs on the property. LPA Nickolas interviewed several facility staff members, revealing that all facility staff members interviewed denied this allegation. LPA Nickolas' interviews with several residents revealed that all residents interviewed could not participate except for one (1) resident, who denied this allegation. The finding is Unsubstantiated. There is no evidence or witnesses to corroborate the allegation.

Allegation #2 “Staff are drinking while on the premises”. The allegation alleged that several facility staff members were drinking at the facility. LPA Nickolas interviewed several facility staff members, revealing that all facility staff members interviewed denied this allegation.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Rayshaun Nickolas
LICENSING EVALUATOR SIGNATURE:

DATE: 10/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2023
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 5
Control Number 56-AS-20230203160839
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: 10/20/2023
NARRATIVE
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LPA Nickolas' interviews with several residents revealed that all residents interviewed could not participate except for one (1) resident, who denied this allegation. The finding is Unsubstantiated. There is no evidence or witnesses to corroborate the allegation.

Allegation #2 “Staff are drinking while on the premises”. The allegation alleged that several facility staff members were drinking at the facility. LPA Nickolas interviewed several facility staff members, revealing that all facility staff members interviewed denied this allegation. LPA Nickolas' interviews with several residents revealed that all residents interviewed could not participate in the interview process except for one (1) resident, who denied this allegation. The finding is Unsubstantiated. There is no evidence or witnesses to corroborate the allegation.

Allegation #3 “Facility is unkempt”. The allegation alleged that the facility is not adequately kept. LPA Nickolas interviewed several facility staff members, revealing some of the facility staff members interviewed denied this allegation, while other members of the facility staff interviewed confirmed this allegation. LPA Nickolas' interviews with several residents revealed that all residents interviewed could not participate in the interview process except for one (1) resident, who denied this allegation. On February 3, 2023, LPA Nickolas conducted an initial complaint investigation visit and completed a facility tour, and determined that the facility was clean and in good repair During today’s visit, LPA Nickolas' completed another tour of the facility, revealing that the facility was clean and in good repair. The finding is Unsubstantiated. There is no evidence or witnesses to corroborate the allegation.

A finding of Unsubstantiated means although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur.

An exit interview was conducted and copy of this report was provided.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Rayshaun Nickolas
LICENSING EVALUATOR SIGNATURE:

DATE: 10/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 5
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
02/03/2023 and conducted by Evaluator Rayshaun Nickolas
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20230203160839

FACILITY NAME:PADUA VILLAGE, INC.FACILITY NUMBER:
360909246
ADMINISTRATOR:SHAWN F. BARRACKSFACILITY TYPE:
735
ADDRESS:11981 MIDWAY RD.TELEPHONE:
(760) 248-6245
CITY:LUCERNE VALLEYSTATE: CAZIP CODE:
92356
CAPACITY:26CENSUS: DATE:
10/20/2023
UNANNOUNCEDTIME BEGAN:
10:35 AM
MET WITH:Shawn Barracks, AdministratorTIME COMPLETED:
02:45 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility staff sleeping during shifts.
Inadequate staffing to meet the needs of the residents.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Rayshaun Nickolas arrived at the facility unannounced to deliver findings on the above allegations. LPA Nickolas met with adminstrator Shawn Barracks and explained the purpose of the visit. The investigation included facility tours, file reviews, and interviews with relevant parties.

Allegation #1 “Facility staff sleeping during shifts”. The allegation alleged that facility staff are sleeping during their shift. LPA Nickolas interviewed several facility staff members, revealing some of the facility staff members interviewed denied this allegation, while other members of the facility staff interviewed confirmed this allegation. LPA Nickolas' interviews with several residents revealed that all residents interviewed could not participate in the interview process, except for one (1) resident who could not confirm or deny this allegation.

Allegation #2 “Inadequate staffing to meet the needs of the residents”. The allegation alleged that the resident staff ratio is inadequate to meet the resident’s needs.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Rayshaun Nickolas
LICENSING EVALUATOR SIGNATURE:

DATE: 10/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 56-AS-20230203160839
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: 10/20/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
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26
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28
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31
32
LPA Nickolas interviewed several facility staff members, revealing some of the facility staff members interviewed denied this allegation, while other members of the facility staff interviewed confirmed this allegation. LPA Nickolas' interviews with several residents revealed that all residents interviewed could not participate in the interview process, except for one (1) resident who had no concerns about residing at the facility. LPA Nickolas' file reviews revealed that the facility receives supplemental funding for one-to-one (1:1) staffing for several residents in care from an outside agency. The investigation into this allegation revealed that several residents in care receiving supplemental funding for 1:1 staffing are not receiving 1:1 care.

Based on the evidence gathered during the investigation, 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.

An exit interview was conduct were a copy of this report (LIC 9099), LIC 9099D, and appeal rights were discussed and provide.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Rayshaun Nickolas
LICENSING EVALUATOR SIGNATURE:

DATE: 10/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 56-AS-20230203160839
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: 10/20/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/20/2023
Section Cited
CCR
80065(a)
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80065 Personnel Requirements (a)
Facility personnel shall be competent to provide the services necessary to meet individual client needs ...
This requirement was not met as evidenced by the following:
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7
Licensee shall ensure that all staff are trained on the cited section. Licensee shall submit training records with all staff signatures by the POC due date of 11/20/2023.
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14
Based on interviews, the facility did not ensure that staff working at the facility were not sleeping during their shift, which posed potential a health, safety, and personal rights violation to persons in care.
8
9
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14
Type B
11/20/2023
Section Cited
CCR
85078
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2
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85078 Responsibility for Providing Care and Supervision.
(a) In addition to Section 80078, the following shall apply:(1) The licensee shall provide those services identified in the client's needs and services plan as necessary to meet the client's needs.
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The licensee shall submit a list of all residents residing at the facility that receive supplemental funding for 1:1 care, with the staff assigned to provide 1:1 care to said residents, and staff schedules by the POC due 11/20/2023.
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This requirement was not met, as evidenced by the following:
Based on interviews and record reviews, the Licensee did not ensure that 1:1 staffing was provided for those residents receiving supplemental funding for 1:1, which posed a potential health, safety, and personal rights violation to persons in care.
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9
10
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12
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14
 Deficienct Continued
If the Licensee is unable to successfully provide the needs of those residents who receive supplemental funding for 1:1 care. In that case, the Licensee shall notify the funding agency for possible replacement, if applicable, and submit proof to the RO by the POC due 11/20/2023 that they are working with the funding agency.
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: 10/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5