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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 361800222
Report Date: 08/24/2021
Date Signed: 08/24/2021 02:10:41 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
08/18/2021 and conducted by Evaluator Stephanie Williams
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20210818110654
FACILITY NAME:11772 JUSTINE WAYFACILITY NUMBER:
361800222
ADMINISTRATOR:SATTIEWHITE, KOLICEFACILITY TYPE:
735
ADDRESS:11772 JUSTINE WYTELEPHONE:
(760) 991-6602
CITY:ADELANTOSTATE: CAZIP CODE:
92301
CAPACITY:4CENSUS: 4DATE:
08/24/2021
UNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Shanell KnowlesTIME COMPLETED:
02:20 PM
ALLEGATION(S):
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Staff did not seek timely medical attention for the clients after carbon monoxide exposure
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Stephanie Williams made an unannounced visit to the facility in order to initiate a complaint investigation into the above allegation. LPA met with House Manager, Shanell Knowles, and discussed the purpose of the visit. The investigation consisted of records review, direct observation, and interviews with staff.

LPA interviewed Staff #1 (S1) who stated that on 8/17/2021, the carbon monoxide alarm went off inside the facility. The clients were evacuated from inside the facility by staff members, except for one client, who refused. Facility staff also called 911. According to S1, the fire department and gas company arrived, who discovered that the carbon monoxide exposure came from a loose laundry hose. Facility staff called a nurse hotline who recommended that all clients be taken to urgent care to get tested for carbon monoxide poisoning. S1 stated that the clients were not immediately taken to urgent care due to insufficient staff; instead, the facility staff called the clients physicians, who requested the lab works but was unable to conduct an in-home visit at the time the call was made. S1 stated that according to consumer notes, two clients
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Stephanie Williams
LICENSING EVALUATOR SIGNATURE:

DATE: 08/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2021
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 18-AS-20210818110654
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: 11772 JUSTINE WAY
FACILITY NUMBER: 361800222
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/24/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/25/2021
Section Cited
CCR
80075(a)
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80075 Health Related Services (a) The licensee shall ensure that each client receives necessary first aid and other needed medical or dental services, including arrangement for and/or provision of transportation to the nearest available services. This requirement is not being met as evidenced by:
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The licensee shall take or arrange for all four clients to be medically evaluated for carbon monoxide poisoning and send proof (photos/physician notes/documentation) to the Department by POC date of 8/25/2021.
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Based on interviews with S1, the licensee did not ensure that four of four clients received medical services after confirmed carbon monoxide exposure. This is an immediate health and safety risk to clients 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: Efren Malagon
LICENSING EVALUATOR NAME: Stephanie Williams
LICENSING EVALUATOR SIGNATURE:

DATE: 08/24/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 3
Control Number 18-AS-20210818110654
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: 11772 JUSTINE WAY
FACILITY NUMBER: 361800222
VISIT DATE: 08/24/2021
NARRATIVE
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reported symptoms of carbon monoxide exposure. S1 stated that to this date, the clients have not been medically evaluated.

Based on the evidence gathered during today's visit, the allegation is SUBSTANTIATED. A finding that the complaint is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met.

An exit interview was conducted where this report was discussed and a copy of this report was provided to Knowles at the conclusion of the visit.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Stephanie Williams
LICENSING EVALUATOR SIGNATURE:

DATE: 08/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 3