361880596-6-14-2023-56-AS-KCLS-CT3U62-20230623151736

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 361880596
Report Date: 06/14/2023
Date Signed: 06/14/2023 03:32:35 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
06/09/2023 and conducted by Evaluator Rayshaun Nickolas

PUBLIC

COMPLAINT CONTROL NUMBER: 56-AS-20230609092339

FACILITY NAME:	CAROLINE STREET		FACILITY NUMBER:	361880596
ADMINISTRATOR:	PATRICIA WOODS		FACILITY TYPE:	735
ADDRESS:	14461 CAROLINE ST		TELEPHONE:	(442) 249-1310
CITY:	ADELANTO	STATE: CA	ZIP CODE:	92301
CAPACITY:	4	CENSUS: 4	DATE:	06/14/2023
		UNANNOUNCED	TIME BEGAN:	10:40 AM
MET WITH:	Shazet Knowles, house manager		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Resident eloped from facility due to lack of supervision.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Rayshaun Nickolas made an unannounced visit to the facility to initiate a compliant investigation and deliver the finding on the above allegation. LPA met with house manager, Shazet Knowles and explained the purpose of the visit. The investigation included a file review and interviews with relevant parties.

The allegation alleged that resident #1 (R1) wandered away from the facility on June 8, 2023, and neighbors posted about it on social media. The allegation alleged that the police were called, and R1 was returned to the facility. The allegation alleged that the reporting party (RP) believes there is a lack of supervision at the facility because the RP had observed members of the facility staff outside on their phones, ignoring the residents.

LPA Nickolas’ interview with staff #1 (S1) confirmed that R1 was away without leave (AWOL) from the facility on June 8, 2023.

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-20230609092339

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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S1 stated they were mopping under the table, medications were already administered, and staff #2 (S2) was on their phone. S1 stated that the front door was open because two (2) residents were sitting outside on the porch, and R1 walked out the door. S1 stated that they let S2 know, and as S1 was about to call 911, S2 went out to look for R1. S1 stated that S2 returned to the facility without R1. Therefore, S1 went looking for R1 in the company van. S1 stated that as they were searching the neighborhood for R1, the police turned on their siren, and ask S1 if they were looking for someone. S1 stated that R1 was in the back seat of the police car.

LPA Nickolas’ interview with S2 confirmed that R1 AWOL’ed from the facility on June 8, 2023. S2 stated that the facility has two (2) caregivers per shift. S2 stated they administered medication while S1 was mopping. S2 stated that S1 informed them that R1 had AWOL’ed. However, S1 could not redirect R1 before R1 left the facility because S1 was mopping. S2 stated that after they put away the medications, they looked for R1. LPA Nickolas’ review of the facility’s shift schedule for the week of June 4, 2023, revealed that the facility had two (2) caregivers working the morning and afternoon shifts.

During today's visit, LPA Nickolas’ did hear the alarms activate when the front door was opened in the facility. However, although the facility is adequately staffed to meet R1's needs, the staff on duty were preoccupied. They were not able to redirect R1 in time or were not able to look for R1 right away.The finding 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.

LPA Nickolas will follow up with R1's placement agency to discuss the reassessment of R1's level of care.

An exit interview was conduct were a copy of this report (LIC 9099), LIC 9099D, and appeal rights were emailed 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-20230609092339

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 07/14/2023 Section Cited CCR 80065(a)	1 2 3 4 5 6 7	80065 Personnel Requirements (a) (a) Facility personnel shall be competent to provide the services necessary to meet individual client needs and shall, at all times, be employed in numbers necessary to meet such needs.	1 2 3 4 5 6 7	The Licensee shall ensure that all facility staff are trained on the cited section. The Licensee shall also forward training records with staff signatures to the regional office (RO) by the POC due date.
	8 9 10 11 12 13 14	This requirement was not met, as evidenced by the following: Based on the interviews, the facility staff did not ensure to provide adequate supervision of R1, which poses a potential health, safety, and person rights violation to persons in care.	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: 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)

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