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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 366402567
Report Date: 03/07/2022
Date Signed: 03/07/2022 02:40:44 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
03/02/2022 and conducted by Evaluator Shaunte Henry
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20220302132411
FACILITY NAME:INLAND ADULT DEVELOPMENTAL CENTERFACILITY NUMBER:
366402567
ADMINISTRATOR:DORIS EKANEMFACILITY TYPE:
775
ADDRESS:10221-B TRADEMARK STREETTELEPHONE:
(909) 483-1310
CITY:RANCHO CUCAMONGASTATE: CAZIP CODE:
91730
CAPACITY:45CENSUS: 40DATE:
03/07/2022
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Kendrick Ancrum, DirectorTIME COMPLETED:
01:40 PM
ALLEGATION(S):
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Facility failed to provide prompt medical care to injured client
Due to staff neglect resident was injured
INVESTIGATION FINDINGS:
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On 3/7/22, Licensing Program Analyst (LPA) Shaunte Henry conducted an unannounced visit for the purpose of initiating a complaint investigation for the above allegations. The LPA met with Doris Ekanem, explained the purpose of the visit and was granted entry.

The investigation, which consisted of interviews and file review revealed the following:
On 12/10/21 at approximately 9 AM, Client 1 (C1) was being transported to the day program by Staff 1 (S1) on 12/10/21. Another vehicle caused S1 to brake quickly, which caused C1 to fall out of their wheelchair. C1 landed on their left shoulder/arm. C1 was not securely fastened in the wheelchair seat belt.
***Continued on 9099C***
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Shaunte Henry
LICENSING EVALUATOR SIGNATURE:

DATE: 03/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2022
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-20220302132411
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: INLAND ADULT DEVELOPMENTAL CENTER
FACILITY NUMBER: 366402567
VISIT DATE: 03/07/2022
NARRATIVE
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***Continued from 9099***

S1 phoned program director Ekanem and Ekanem and Staff 2 (S2) arrived at the scene of the accident. Ekanem, S1, and S2 assisted C1 back into their chair. Ekanem assessed C1 who did not appear to have any visible wounds, cuts, or abrasions. C1's responsible party (RP) was contacted and allowed C1 to return to day program. When S1 returned C1 to their home after progam, RP informed S1 that C1 was not right and RP will be taking C1 to the hospital.

On 12/11/21, RP contacted Ekanem to notify her that C1 had fractured their right hip in two places and their neck as a result of falling out of the wheelchair on 12/10/21. On 12/12/21, RP contacted Ekanem and provided an update on C1's injuries. C1 had fractured the right and left hip, with the right hip being broken in two places. C1 had hip surgery on 12/13/21 and was assessed for a neck surgery on 12/21/21. The facility conducted an internal investigation on 12/14/21 through 12/15/21 and S1 admitted that while they secured the wheelchair, they did not check whether C1's seat belt was secured.

Based on LPAs observations and interviews, which were conducted, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6) is being cited on the attached LIC9099D. An exit interview was conducted where this report, LIC 811, 9099D and appeal rights were provided to Kendrick Ancrum, Director.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Shaunte Henry
LICENSING EVALUATOR SIGNATURE:

DATE: 03/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3
Control Number 18-AS-20220302132411
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: INLAND ADULT DEVELOPMENTAL CENTER
FACILITY NUMBER: 366402567
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/07/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/07/2022
Section Cited
CCR
82075(a)
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Health Related Services: The licensee shall ensure that each client receives necessary first aid and other needed medical services...This requirement was not met as evidenced by:
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The facility will review the cited regulation, sign, date and provide proof to the department by the POC date.
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Based on interviews and file review: On 12/10/21 around 9am, C1 fell out of the wheelchair. C1 returned to the day program and was taken to the hospital by their
(continued in next box)
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responsible party when C1 was transported home after day program was over. This is an immediate health and safety risk to clients in care.
Type A
03/07/2022
Section Cited
CCR
82072(a)(2)
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Personal Rights: Each client shall have personal rights...To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs. This requirement was not met as evidenced by:
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The facility shall provide in service training to all staff and provide proof to the department by the POC date.
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Based on interviews, S1 stated that they did not check whether C1's seat belt was secured while securing C1's wheelchair. 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: Nedra Brown
LICENSING EVALUATOR NAME: Shaunte Henry
LICENSING EVALUATOR SIGNATURE:

DATE: 03/07/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3