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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 361880596
Report Date: 11/16/2023
Date Signed: 11/16/2023 12:55:34 PM

Unsubstantiated


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
11/09/2023 and conducted by Evaluator Anna Bueno
COMPLAINT CONTROL NUMBER: 56-AS-20231109112356
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:
11/16/2023
UNANNOUNCEDTIME BEGAN:
09:04 AM
MET WITH:Shazet Knowles, house managerTIME COMPLETED:
12:58 PM
ALLEGATION(S):
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Resident was attacked by another resident due to lack of supervision.
Staff did not to prevent residents sleep from being disturbed by another resident.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Anna Bueno conducted an unannounced visit to the facility to initiate the investigation the above mentioned allegations and deliver findings. LPA identified herself to direct support staff (S1) Kandy Gastelum who was informed of the reason for today’s visit. House manager Shazet Knowles arrived shortly and was informed by S1 of LPA's visit. The investigation included staff interviews, and records review. The Department was not able to interview Client 1 (C1).

The allegations are that Resident was attacked by another resident due to lack of supervision and that Staff did not to prevent residents sleep from being disturbed by another resident. It is alleged that on 11/4/23, C1 attacked C2 in C2's bedroom. LPA spoke with Client 2 (C2) who confirmed that they were attacked by C1. LPA interviews with staff revealed that the facility do not restrain clients and, on 11/4/23, Staff 2 (S2) and Staff 3 (S3) were attempting to verbally redirect C1 from leaving the property. Interviews further reveal that C1 responded to staff redirection by breaking into C2's bedroom which is located near the front door. Interviews reveal that C1 then attacked C2 while staff continued to redirect C1 to leave C2's bedroom. Staff shared that upon exiting C2's room, C1 successfully eloped from the facility. S2 followed C1 on foot while S3 remained at the facility to attend to C2 and the other clients.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Anna Bueno
LICENSING EVALUATOR SIGNATURE:

DATE: 11/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2023
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 2
Control Number 56-AS-20231109112356
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: 11/16/2023
NARRATIVE
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LPA reviewed records showing that C1 has a documented behavior of elopement, physical aggression, and property destruction. Interviews with staff and records obtained reveal that the facility is also working with behavioral services in implementing effective interventions for C1. Based on the information, the allegations are therefore unsubstantiated.

A finding of UNSUBSTANTIATED means although the allegations may have happened or are valid, there is no preponderance of evidence to prove the alleged violations did or did not occur. An exit interview was conducted with house manager Knowles and a copy of this report was provided.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Anna Bueno
LICENSING EVALUATOR SIGNATURE:

DATE: 11/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2