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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 361880596
Report Date: 07/10/2023
Date Signed: 08/02/2023 01:07:46 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
07/03/2023 and conducted by Evaluator Rayshaun Nickolas
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20230703161532
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:
07/10/2023
UNANNOUNCEDTIME BEGAN:
09:48 AM
MET WITH:Shazet Knowles, house managerTIME COMPLETED:
02:43 PM
ALLEGATION(S):
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Resident eloped from facility due to lack of supervision.
Resident sustained injuries due to lack of supervision.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Rayshaun Nickolas visited the facility unannounced to initiate an investigation and deliver the finding on the above allegations. LPA met with house manager Shazet Knowles and explained the purpose of the visit. The investigation included file review, facility tour, and interviews with relevant parties.

Allegation #1 “Resident eloped from facility due to lack of supervision”. The allegation alleged that resident #1 (R1) wandered away from the facility to a neighbor’s home. LPA Nickolas’ interview with staff #1 (S1) revealed that upon returning to the facility from an outing with R1, R1 exited the vehicle and started running away. S1 stated that they were the only employee with R1 at the time. LPA Nickolas’ attempted to interview R1; however, R1 could not participate in the interview process. LPA Nickolas’ also interviewed two (2) other residents in care; however, they did not witness the incident.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Rayshaun Nickolas
LICENSING EVALUATOR SIGNATURE:

DATE: 07/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/10/2023
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-20230703161532
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: 07/10/2023
NARRATIVE
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Allegation #2 “Resident sustained injuries due to lack of supervision”. The allegation alleged that a neighbor assaulted R1 for trespassing on their property. LPA Nickolas’ interview with S1 revealed that S1 confirms that a neighbor assaulted R1 for trespassing on their property. LPA Nickolas’ attempted to interview R1; however, R1 could not participate in the interview process. LPA Nickolas’ also interviewed two (2) other residents in care; however, they did not witness the incident.

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 immediate Civil Penalty of $1,000 is being assessed for the repeat violation of the California Code of Regulation (CCR), Section 80065(a).

LPA Nickolas' completed an exit interview was conducted, where copies of this report (LIC 9099), LIC 9099D, LIC 421IM, and appeal rights were discussed and provided.

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

DATE: 07/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/10/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Citations on this Visit Report are Under Appeal!

Control Number 56-AS-20230703161532
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: 07/10/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Under Appeal
Type B
07/25/2023
Section Cited
CCR
80065(a)
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Personnel Requirements 80065(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.
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Licensee stated that additional training will be provided to all staff. Licensee shall submit signed training to the RO by POC due date. Licensee also stated that they would also speak with the other Licensee about other preventaton solutions.
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This requirement was not met, as evidenced by the following:

Based on interviews, the Licensee needed to ensure to employ more staff to meet R1's needs, which posed an immediate health, safety, and person rights violation to R1.
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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: 07/10/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/10/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3