370808412-9-21-2023-08-AS-DPOL-CW5TCK-20230929143651

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 370808412
Report Date: 09/21/2023
Date Signed: 09/21/2023 11:30:31 AM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/07/2023 and conducted by Evaluator Renita Hall

COMPLAINT CONTROL NUMBER: 08-AS-20230607124851

FACILITY NAME:	CLARK ADULT RESIDENTIAL FACILITY		FACILITY NUMBER:	370808412
ADMINISTRATOR:	ADRIANNE CLARK		FACILITY TYPE:	735
ADDRESS:	2402 EUCLID AVENUE		TELEPHONE:	(619) 579-0783
CITY:	EL CAJON	STATE: CA	ZIP CODE:	92019
CAPACITY:	4	CENSUS: 2	DATE:	09/21/2023
		UNANNOUNCED	TIME BEGAN:	11:15 AM
MET WITH:	Andriene Clark, Director		TIME COMPLETED:	11:40 AM

ALLEGATION(S):

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Facility did not maintain accurate records for client cash resources
Facility did not obtain PRN medications as prescribed
Facility menu was not available for review

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Renita Hall conducted an unannounced visit regarding the above-mentioned allegations to deliver findings. LPA was allowed entry by the Adrienne Clark, Director. LPA identified herself and disclosed the purpose of the visit with the Director.

The Department investigated the above listed complaint allegations. The investigation consisted of a tour of the facility,interviews residents, and records review.

On June 12, 2023, residents were interviewed and stated that they eat "gourmet" food. Residents were able to provide information on their favorite foods and the restaurants they like to eat at.

Review of records showed that PRN's were available for all medications and resident had menus available. An annual review was conducted by the Department on June 1, 2023 and client cash resources was counted and were correct.

Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Renita Hall
LICENSING EVALUATOR SIGNATURE:	DATE: 09/21/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 08-AS-20230607124851

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: CLARK ADULT RESIDENTIAL FACILITY	FACILITY NUMBER: 370808412
	VISIT DATE: 09/21/2023

NARRATIVE

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An email dated 02/09/23 from San Diego Regional Center that Clark ARF is "deemed in compliance with the HCBS-final Rule by SDRC."

Based on the evidence, interview conducted, and record review(s), that Facility did not maintain accurate records for client cash resources; Facility did not obtain PRN medications as prescribed; Facility menu was not available for review, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. However, these corrections had been made prior to the Department's visit and San Diego Regional Center had found facility to be in compliance.

An exit interview was conducted with Adrienne Clark, Director. A copy of this report and Licensee's Rights (LIC 9058 03/22) were provided to the Director and her signature on this report confirms receipt of the Licensee Rights

SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Renita Hall
LICENSING EVALUATOR SIGNATURE:	DATE: 09/21/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2023

LIC9099 (FAS) - (06/04)

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