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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366425780
Report Date: 08/17/2021
Date Signed: 08/17/2021 10:59:34 AM

Document Has Been Signed on 08/17/2021 10:59 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:SPECIALIZED RESIDENTIAL LUPINEFACILITY NUMBER:
366425780
ADMINISTRATOR:CHAZTINEY CLOUDFACILITY TYPE:
735
ADDRESS:22334 LUPINE RDTELEPHONE:
(760) 247-2391
CITY:APPLE VALLEYSTATE: CAZIP CODE:
92308
CAPACITY: 4CENSUS: 4DATE:
08/17/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:Lawanna JonesTIME COMPLETED:
11:08 AM
NARRATIVE
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Licensing Program Analysts (LPAs) Natalie Gayoso and Melody Brown conducted an unannounced visit to the facility to deliver findings. LPAs introduced themselves and discussed the purpose to today’s visit with Administrator, Lawanna Jones

LPAs informed the administrator that today’s case management visit is to address the deficiencies found within an Incident Report and SOC 341 received on May 2, 2019. The incident report involved neglect/lack of care and supervision of a client in care. The report indicated a staff member walked in on two (2) clients engaged in sexual activity on April 28, 2019. Client 1 (C1) offered Client 2 (C2) cigarettes and soda in exchange for sex. Per the needs and services plan dated June 19, 2018. C1 has a history of sexually inappropriate behaviors.

C2’s most recent Individualized Placement Plan (IPP), dated March 12, 2019, reads “After a recent hospitalization, the physician believed that C2's mental capacity (such as the ability to give consent to sexual activity) was diminishing." The needs and service plan dated March 12, 2019 for C2 indicates they require constant supervision while in the community and at home.


Per the department’s investigation, the administrator, house manager and Behavior Specialist were to take additional measures to prevent C1 from entering C2's room to engage in sexual activity by increasing supervision and installing a lock on the bathroom door that separates the two clients. The bathroom lock can only be unlocked while in C2's room.

The incident was investigated by the Department in which nine (9) interviews were conducted revealing that staff failed to meet the residents needs by failing to increase supervision of C1 to prevent sexual activity with C2. Refer to LIC 809D for deficiency cited

An exit interview was conducted and a copy of this report, LIC 809D, and Appeal Rights were given to the Administrator.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Natalie Gayoso
LICENSING EVALUATOR SIGNATURE: DATE: 08/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/17/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/17/2021 10:59 AM - It Cannot Be Edited

Citations on this Visit Report are Under Appeal!


Created By: Natalie Gayoso On 08/17/2021 at 10:29 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: SPECIALIZED RESIDENTIAL LUPINE
FACILITY NUMBER: 366425780

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/17/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Under Appeal
Type A
08/18/2021
Section Cited
CCR
85078(a)(1)

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Responsibility for Providing Care and Supervision(a)(1):The licensee shall provide those services identified in the client's needs and services plan as necessary to meet the client's needs. This requirement was not met as evidenced by:

Based on interviews conducted, and records
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Administrator agrees to conduct an in-service traininng with staff regarding supervision and needs and service plans by POC date 8/18/21
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reviewed staff failed to provide supervision to
C1 & C2 as indicated in their needs and service plan which states that C1 exhibits sexually inappropriate behaviors and C2 must be constantly supervised due to their diminishing mental capacity. This is an immediate health and safety hazard 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.
SUPERVISOR'S NAME:Karen Clemons
LICENSING EVALUATOR NAME:Natalie Gayoso
LICENSING EVALUATOR SIGNATURE:
DATE: 08/17/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/17/2021


LIC809 (FAS) - (06/04)
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