<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 361800205
Report Date: 09/16/2021
Date Signed: 09/16/2021 12:17:12 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
RIVERSIDE, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/08/2019 and conducted by Evaluator Crystal Colvin
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20191108100012
FACILITY NAME:ESPINOZA ADULT CARE HOME IIFACILITY NUMBER:
361800205
ADMINISTRATOR:LYDIA ESCTIAFACILITY TYPE:
735
ADDRESS:12799 PETALUMA RDTELEPHONE:
(909) 770-3544
CITY:VICTORVILLESTATE: CAZIP CODE:
92392
CAPACITY:4CENSUS: 4DATE:
09/16/2021
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Candice Dubief - Assistant AdministratorTIME COMPLETED:
12:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff verbally abused resident

Staff physically abused resident

Staff physically restrained resident
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Crystal Colvin made an unannounced visit to the facility for the purpose of delivering findings for the complaint investigation with the above allegation(s). LPA Colvin spoke with Assistant Administrator Candice Dubief, and reviewed the following findings:

Regarding the allegation "Staff verbally abused resident": During this investigation, LPA Colvin confirmed that on October 29, 2019, facility staff member #1 (S1) was found to have been acting in the capacity as a staff member for Espinoza Adult Care Home II when S1 arrived at the Adult Day Program (ADP) to pick up one of the facility’s residents (R1). Multiple interviews conducted during this investigation confirmed that S1 verbally abused R1 while S1 was picking up R1 from the ADP. According to the evidence collected, S1 was observed to have cursed at R1 and called R1 names such as “bastard” and “piece of shit”. Therefore, based on interviews conducted, the allegation of “Staff verbally abused resident" is SUBSTANTIATED.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Crystal Colvin
LICENSING EVALUATOR SIGNATURE:

DATE: 09/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2021
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 4
Control Number 18-AS-20191108100012
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
RIVERSIDE, CA 92507

FACILITY NAME: ESPINOZA ADULT CARE HOME II
FACILITY NUMBER: 361800205
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/16/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/14/2021
Section Cited
CCR
80065(l)
1
2
3
4
5
6
7
Personnel Requirements: (l) Personnel shall provide for the care and safety of persons without physical or verbal abuse, exploitation or prejudice. This requirement was not met by:
1
2
3
4
5
6
7
R1 no longer works at the facility. No POC needed.
8
9
10
11
12
13
14
Based on interviews, on 10/29/19, S1 cursed at R1 and called R1 names such as "bastard" and "piece of shit". This was an immediate personal rights violation of R1
8
9
10
11
12
13
14
Type A
07/14/2021
Section Cited
CCR
80072(a)(3)
1
2
3
4
5
6
7
Personal Rights: (a)...each client shall have personal rights which include...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 by:
1
2
3
4
5
6
7
R1 no longer works at facility. NO POC needed.
8
9
10
11
12
13
14
Based on interviews and review of video footage, on October 29, 2019, S1 was found to have caused R1 to fall to the ground and thereafter drag R1 on the ground by their shirt collar. This was an immediate personal rights violation of R1.
8
9
10
11
12
13
14
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: Joel Esquivel
LICENSING EVALUATOR NAME: Crystal Colvin
LICENSING EVALUATOR SIGNATURE:

DATE: 09/16/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 18-AS-20191108100012
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
RIVERSIDE, CA 92507
FACILITY NAME: ESPINOZA ADULT CARE HOME II
FACILITY NUMBER: 361800205
VISIT DATE: 09/16/2021
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
Regarding the allegation "Staff physically abused resident": Interviews were conducted and facility documentation was reviewed as well as surveillance footage from R1’s ADP. LPA Colvin confirmed that on October 29, 2019 S1 caused R1 to fall to the ground by grabbing and swinging R1 to the side in order to gain physical control of R1. It was additionally confirmed that after R1 fell to the ground, S1 proceeded to grab R1 by the shirt collar and drag R1 across the ground. Based on interviews and review of surveillance footage, the allegation of "Staff physically abused resident" is SUBSTANTIATED.

Regarding the allegation "Staff physically restrained resident": Interviews were conducted and facility documentation was reviewed as well as surveillance footage from R1’s ADP. During the investigation it was confirmed that S1 used bodily force to restrain R1 on October 29, 2019 while picking R1 up from R1's ADP. S1 utilized means of restraint on R1 on more than one occasion by pulling R1's arms behind R1's back and securing them in a lock with S1's arms/hands. Additionally, during the incident between S1 and R1, S1 manages to get R1 onto the ground and uses their legs to hold R1 onto the ground. The evidence does not show that R1 was in danger of hurting himself or others and therefore did not need to be physically restrained by S1. Therefore, based on interviews and review of surveillance footage, the allegation of "Staff physically restrained resident" is SUBSTANTIATED.

A finding that the complaint is SUBSTANTIATED means that the allegations are valid because the preponderance of the evidence standard has been met.

Due to observations made by LPA Colvin, the facility was cited, and deficiencies noted on LIC 9099Ds. An exit interview was conducted where this report and appeal rights were discussed. A copy of all reports, forms, and appeal rights were provided to Assistant Administrator Candice Dubief during the exit interview.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Crystal Colvin
LICENSING EVALUATOR SIGNATURE:

DATE: 09/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 4
Control Number 18-AS-20191108100012
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
RIVERSIDE, CA 92507

FACILITY NAME: ESPINOZA ADULT CARE HOME II
FACILITY NUMBER: 361800205
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/16/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/14/2021
Section Cited
CCR
80072(a)(3)
1
2
3
4
5
6
7
Personal Rights: (a)...each client shall have personal rights which include...: (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 by:
1
2
3
4
5
6
7
R1 no longer works at facility. No POC needed
8
9
10
11
12
13
14
Based on interviews and observations, the Licensee did not comply with the above regulation with 1 out of 4 residents. S1 restrained R1 on 10/29/19 by pinning R1's arms behind their back. S1 also held R1 to the ground with their legs. This was an immediate personal rights violation.
8
9
10
11
12
13
14
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: Joel Esquivel
LICENSING EVALUATOR NAME: Crystal Colvin
LICENSING EVALUATOR SIGNATURE:

DATE: 09/16/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 4