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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 361880596
Report Date: 06/14/2023
Date Signed: 06/14/2023 03:42:00 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
05/16/2023 and conducted by Evaluator Rayshaun Nickolas
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20230516144029
FACILITY NAME:CAROLINE STREETFACILITY NUMBER:
361880596
ADMINISTRATOR:PATRICIA WOODSFACILITY TYPE:
735
ADDRESS:14461 CAROLINE STTELEPHONE:
(442) 249-1310
CITY:ADELANTOSTATE: CAZIP CODE:
92301
CAPACITY:4CENSUS: 4DATE:
06/14/2023
UNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Shazet Knowles, House managerTIME COMPLETED:
03:55 PM
ALLEGATION(S):
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Resident was able to elope from facility without staff knowledge.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Rayshaun Nickolas made an unannounced visit to the facility to deliver the finding on the above allegation. LPA met with house manager, Shazet Knowles and explained the purpose of the visit. The investigation included file reviews and interviews with relevant parties.

The allegation alleged that on three (3) different occasions (10/05/2022, sometime in 02/2023, and 05/13/2023), resident #1 (R1) eloped from the facility and was roaming the community trying to get inside neighbors' houses. The allegation alleged that sometime in February 2023, the reporting party's (RP's) spouse walked the resident back to the facility, and a member of the facility staff apologized, saying they were administering medication to another client and did not see the resident leave the facility. LPA Nickolas’ interview with staff #1 (S1) revealed that the facility installed alarms on the front and back doors. S1 stated that R1 takes off when they get anxious and need to leave. S1 stated that facility staff members take R1 on walks or to the park to help with R1’s anxiousness. LPA Nickolas' did hear the alarm activate as the front door was opened.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Rayshaun Nickolas
LICENSING EVALUATOR SIGNATURE:

DATE: 06/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2023
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 3
Control Number 56-AS-20230516144029
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: CAROLINE STREET
FACILITY NUMBER: 361880596
VISIT DATE: 06/14/2023
NARRATIVE
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LPA Nickolas' interviews with several members of the facility staff revealed that two (2) staff members are scheduled to work the morning and afternoon shifts. However, facility staff members frequently call out, which results in one (1) member of the facility staff working in the morning and afternoon shifts. LPA Nickolas' review of staff schedules for the week of October 2, 2022, the entire month of February 2023, and May 13, 2023, revealed that, for the most part, the facility has sufficient staff during the weekdays to meet R1's needs. However, the facility does not have sufficient staff on the weekends to meet R1's needs.

Based on the evidence gathered during the investigation, the above allegation is 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 email due to technical difficulties.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Rayshaun Nickolas
LICENSING EVALUATOR SIGNATURE:

DATE: 06/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 56-AS-20230516144029
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: CAROLINE STREET
FACILITY NUMBER: 361880596
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/14/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/30/2023
Section Cited
CCR
85065(b)
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85065 Personnel Requirements (b)

The licensee shall employ staff as necessary to ensure provision of care and supervision to meet client needs.

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The Licensee shall also ensure to employ necessary staffing to meet R1's needs.
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This requirement was not met, as evidenced by the following:

Based on interviews and file review, the Licensee did not ensure to have enough staff to meet R1's need, which poses a potential health, safety, person rights violation.
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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: 06/14/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3