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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 370808482
Report Date: 05/15/2024
Date Signed: 05/15/2024 05:25:38 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, 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
02/09/2021 and conducted by Evaluator Dang Nguyen
COMPLAINT CONTROL NUMBER: 08-AS-20210209131152
FACILITY NAME:DSC - VILLAGE HOUSEFACILITY NUMBER:
370808482
ADMINISTRATOR:KRISTEN HOLLOBAUGHFACILITY TYPE:
735
ADDRESS:6010 HOWELLTELEPHONE:
(619) 460-7333
CITY:LA MESASTATE: CAZIP CODE:
91942
CAPACITY:6CENSUS: 5DATE:
05/15/2024
UNANNOUNCEDTIME BEGAN:
04:15 PM
MET WITH:Support Staff Cora Calilung and Administrator Kristen Hollobaugh and Executive Director Patricia BarberTIME COMPLETED:
05:30 PM
ALLEGATION(S):
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Licensee retained a client not compatible with other clients in care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced subsequent visit to deliver a finding regarding the above prior complaint allegation. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Support Staff Charjaquacia Swift. LPA also spoke with Administrator Kristen Hollobaugh and Executive Director Patricia Barber via phone during the visit.

The Complainant alleged that Licensee retrained Client #1 (C1), whose assaultive behaviors made them incompatible with other clients in care at the facility. [See LIC811 Confidential Names List for a description of C1.] CCLD’s investigation involved an unannounced facility tour / welfare check and review of pertinent facility and third-party care records. The Department also interviewed relevant clients, facility staff, and outside sources.

[CONTINUED ON LIC 9099-C, 1 of 3]
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 05/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2024
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 8
Control Number 08-AS-20210209131152
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: DSC - VILLAGE HOUSE
FACILITY NUMBER: 370808482
VISIT DATE: 05/15/2024
NARRATIVE
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[CONTINUED FROM LIC 9099]

According to C1’s LIC602 Physician’s Report (dated 08/19/2020) and corroborated by their Face Sheet: C1 was 6’2’’ tall and 279 pounds, fully ambulatory, and was diagnosed with “Autism with Intermittent Explosive Disorder.” According to C1’s 05/19/2020 Individual Program Plan (IPP) from San Diego Regional Center (SDRC): C1 had a history of “physical aggression, property destruction, and verbal outbursts.” C1’s “physical assaults would occur when [they were] very angry and consisted of pushing, hitting with an open hand, and kicking,” C1 would sometimes “scream and break things,” and that it was often unclear what the triggers were.

Per their respective Face Sheets, during the complaint allegation time frame: C1 was 32 years old and had “Mild Intellectual Disability.” Client #2 (C2) was 61 years old and had “Severe Intellectual Disability.” Client #3 (C3) was 50 years old and had “Moderate Intellectual Disability.” Client #4 (C4) was 69 years old and had “Moderate Intellectual Disability.” Client #5 (C5) was 55 years old, had “Severe Intellectual Disability,” and was noted to walk “slowly and hold onto walls.” Client #6 (C6) was age 53 and had “Moderate Intellectual Disability.” Prior to the filing of the complaint, C2, C4, C5, and C6 had each lived together at the facility for over 29 years. C3 joined the group in 2010 and lived with this group for a decade. C1 arrived last, moving in during August 2020.

According to Special Incident Reports (SIRs) and Reports of Suspected Dependent Adult Abuse (SOC341s), which Licensee self-submitted to CCLD, and corroborated by police records and by staff and outside source interviews: On 10/11/2020, C1, unprovoked, hit C2 on the back, punched the wall, slammed a door, threw objects, and yelled. On 11/29/2020, C1, unprovoked, hit C3 in the face; C3 was seated in a recliner when that occurred. On 12/18/2020, C1, unprovoked, slapped C3 on their neck (causing redness for which staff applied an ice pack); C3 was using a computer/tablet when that occurred. On 12/29/2020, C1, unprovoked, approached C3 in the facility’s living room and slapped them across the face; C3 was seated in a recliner when that occurred. On 01/26/2021, C1, unprovoked, hit C4’s head hard enough to cause C4's glasses to fall off. C4 was seated at the dining room table when that occurred. C1 also tried to hit the staff who intervened to protect C4. For each of the above incidents, Licensee’s staff immediately separated the clients to prevent further harm and timely notified law enforcement, San Diego Regional Center (SDRC), the Long-Term Care Ombudsman, and CCLD. Per records and interviews, C2, C3, and C4 did not suffer serious or lasting injuries from these incidents. [CONTINUED ON LIC 9099-C, 2 of 3]
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 05/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 8
Control Number 08-AS-20210209131152
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: DSC - VILLAGE HOUSE
FACILITY NUMBER: 370808482
VISIT DATE: 05/15/2024
NARRATIVE
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[CONTINUED FROM LIC 9099-C, 1 of 3]

According to staff interviews and Licensee’s own “Behavioral Data” documentation on C1: There was an incident on 10/09/2020 when C1 told C5, with profanity, their desire to shoot and kill C5. There was also an incident on 11/20/2020 when C1, unprovoked, rushed towards C6 with balled-up fists. Staff blocked C1 in time to allow C6 to get away and move outside, but C1 continued to yell at C6. On 12/30/2020, C1 tried to hit a facility staff in the face but missed, hitting their arm instead. On 01/26/2021, C1 hit one staff in the arm, then tried to hit a second staff as that person was blocking C1 from hitting a client. From 12/17/2020 through 02/10/2021, there were at least 11 instances of C1 becoming visibly agitated while hallucinating. This most often manifested as C1 hearing voices and either mumbling back or yelling loudly/angrily back at those imagined voices, often with profanity. There were multiple accounts of C1 slamming doors, hitting the wall, or throwing objects around in anger.

For this investigation, CCLD either interviewed or attempted to interview every client in care and every direct-care staff who worked at the facility during the allegation time frame. Available staff interviews and outside source interviews aligned to show: Although each client had their own behaviors, C2 through C6 had lived together many years at the facility with overall calm and compatibility. Staff unanimously reported that C1, with their unpredictable aggressive behavior, was incompatible living with C2 through C6, who were each older, slower, and frailer than C1. Whereas C1 instigated aggression towards other clients, the other clients did not do the same towards C1. Multiple direct care staff and an outside source told CCLD that C1’s presence at the facility caused fear for other clients in care, and that their concerns were conveyed to facility upper management. Four (4) of the six (6) clients CCLD spoke to (including C1) were not able to be qualified as witnesses for this case. However, C4 confirmed C1 had previously hit them on the neck “for no reason,” and that they had become fearful of C1.

Interview of a facility manager showed: Licensee was aware of C1’s prior history of aggression (from before move-in), C1’s hitting housemates at the facility was usually unprovoked, and more than one client was indeed fearful around C1. By the commencement of CCLD’s investigation on 02/18/2021, Licensee had increased the number of direct care staff present at the facility from two to three. However, Licensee had neither sought SDRC assistance with relocating C1 to another facility, nor issued a 30-day eviction notice to C1. (The facility’s written House Rules, which all clients sign at time of move in, included: “10. Don’t hurt or try to hurt other people,” and “11. Don’t intentionally break or try to break property.”) [CONTINUED ON LIC 9099-C, 3 of 3]
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 05/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 8
Control Number 08-AS-20210209131152
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: DSC - VILLAGE HOUSE
FACILITY NUMBER: 370808482
VISIT DATE: 05/15/2024
NARRATIVE
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[CONTINUED FROM LIC 9099-C, 2 of 3] In February 2021, Licensee arranged for C1 to be seen by a psychiatrist, who added a routine anticonvulsant medication to C1’s prescriptions and increased the dosage of their as-needed (PRN) antipsychotic medication, which Licensee said reduced C1’s aggression. According to SIRs and SOC341s which Licensee subsequently submitted to CCLD: On 03/02/2021, C2 was sitting at the dining room table when C1 approached them and hit them on the shoulder, unprovoked. C1 then kicked chairs before staff escorted them away and gave C1 said PRN medication. On 10/12/2021, C1 was yelling inside their bedroom. As a staff person was giving C1 their PRN medication, C1 punched them in the stomach.

According to interview of C1’s SDRC social worker: DSC Village House is a “Service Level 4-H” facility. In November 2021, Licensee coordinated with SDRC to relocate C1 to another “Service Level 4-H” CCLD-licensed Adult Residential Facility (ARF), also operated by Licensee. [According to the Department of Developmental Services, which oversees SDRC: "Level 4" ARF facilities offer the highest level of “care, supervision, and professionally supervised training for persons with deficits in self-help skills…and/or severe disruptive…behavior.”] As of May 2024, C1 was well adjusted at their new facility and not exhibiting aggressive behavior towards current housemates, who the social worker said were closer in age and physical stature to C1, compared to the prior housemates at DSC Village House.

CCLD recognized Licensee’s direct care staff quickly intervened when necessary to break up client altercations, and that over time Licensee helped C1 achieve an overall stabilization in their behaviors. CCLD did not conclude that Licensee was incapable of meeting C1’s behavioral and care needs. However, based on records and interviews, the preponderance of evidence showed that at least during the complaint allegation time frame, Licensee retrained a client (C1) at a facility (i.e., DSC Village House) where and while they were not compatible with the other preexisting clients in care (C2 through C6), to the detriment of those latter clients’ safety and comfort. The complaint allegation is therefore Substantiated. One (1) deficiency was cited per California Code of Regulations, Title 22 (refer to the attached LIC 9099-D). A Plan of Correction was jointly developed with the licensee.

An exit interview was conducted with Hollobaugh Barber, to whom a copy of this report, the LIC 9099-D, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided.
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 05/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 8
Control Number 08-AS-20210209131152
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: DSC - VILLAGE HOUSE
FACILITY NUMBER: 370808482
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/15/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/15/2024
Section Cited
CCR
85068.4(a)(3)
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85068.4 Acceptance and Retention Limitations: “(a) The Licensee shall not accept or retain the following: (3) Persons who have needs that are in conflict with the needs of other clients or the program of services offered.” This requirement was not met, as evidenced by:
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According to interview of facility manager and SDRC, C1 moved out of the facility in November 2021, relocating to a different setting where they are getting along fine with housemates. This action resolved the deficiency. Licensee agreed that going forward, it will consider not only the behavioral history, but also the personalities, current ages (i.e., 50s and 60s), developmental capacity (i.e., moderate to severe intellectual disability), and physical stature of the current clients of DSC Village House when assessing/evaluating potential new client(s) for move-in, and that it will prioritize the needs of existing clients.
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Based on records and interviews: For 1 of 6 clients (C1), Licensee accepted and retained a client whose needs were in conflict with the needs of other clients already in care at the facility. This posed a potential safety and personal rights risks to persons 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: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 05/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 8
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
02/09/2021 and conducted by Evaluator Dang Nguyen
COMPLAINT CONTROL NUMBER: 08-AS-20210209131152

FACILITY NAME:DSC - VILLAGE HOUSEFACILITY NUMBER:
370808482
ADMINISTRATOR:KRISTEN HOLLOBAUGHFACILITY TYPE:
735
ADDRESS:6010 HOWELLTELEPHONE:
(619) 460-7333
CITY:LA MESASTATE: CAZIP CODE:
91942
CAPACITY:6CENSUS: 5DATE:
05/15/2024
UNANNOUNCEDTIME BEGAN:
04:15 PM
MET WITH:Support Staff Cora Calilung and Administrator Kristen Hollobaugh and Executive Director Patricia BarberTIME COMPLETED:
05:30 PM
ALLEGATION(S):
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Licensee did not provide staff training to meet client’s behavioral needs.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced subsequent visit to deliver a finding regarding the above prior complaint allegation. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Support Staff Charjaquacia Swift. LPA also spoke with Administrator Kristen Hollobaugh and Executive Director Patricia Barber via phone during the visit.

The Complainant alleged that Licensee did not provide its direct care staff with training needed to handle Client #1’s (C1) aggressive behaviors. [See LIC811 Confidential Names List for a description of C1.] CCLD’s investigation involved an unannounced facility tour / welfare check and review of pertinent facility and third-party care and training records. The Department also interviewed relevant clients, facility staff, and outside sources.


[CONTINUED ON LIC 9099-C, 1 of 2]
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 05/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 6 of 8
Control Number 08-AS-20210209131152
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: DSC - VILLAGE HOUSE
FACILITY NUMBER: 370808482
VISIT DATE: 05/15/2024
NARRATIVE
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[CONTINUED FROM LIC 9099-A]

According to C1’s LIC602 Physician’s Report (dated 08/19/2020) and corroborated by their Face Sheet: C1 was 6’2’’ tall and 279 pounds, fully ambulatory, and was diagnosed with “Autism with Intermittent Explosive Disorder.” According to C1’s 05/19/2020 Individual Program Plan (IPP) from San Diego Regional Center (SDRC): C1 had a history of “physical aggression, property destruction, and verbal outbursts.” C1’s “physical assaults would occur when [they were] very angry and consisted of pushing, hitting with an open hand, and kicking,” C1 would sometimes “scream and break things,” and that it was often unclear what the triggers were.

According to Special Incident Reports (SIRs) and Reports of Suspected Dependent Adult Abuse (SOC341s), which Licensee self-submitted to CCLD, and corroborated by police records and by staff and outside source interviews, and by Licensee’s own “Behavioral Data” documentation: From October 2020 through January 2021, C1 indeed had multiple physical altercations with other clients in care and facility staff. On each of those occasions, Licensee’s staff quickly intervened and/or separated the clients to prevent further harm and timely notiifed law enforcement, San Diego Regional Center (SDRC), the Long-Term Care Ombudsman, and CCLD. Per available records and interviews, there were no serious or lasting injuries to any persons involved.

Manager interview, corroborated by training records, showed: Prior to C1 moving to the facility, Licensee provided its direct care staff with around 20 hours of orientation training on how to manage client assaultive behaviors. During October 2020, Licensee provided direct care staff an additional one-hour training on “Behavioral Strategies,” with particular emphasis on a detailed behavioral plan specific to C1’s behaviors. C1’s written behavioral plan was developed in consultation with Licensee’s third-party contracted Behavioral Consultant (P1), who was a graduate-level, Board Certified Behavior Analyst (BCBA). Per interview of P1, around the complaint time frame, they personally taught a separate training class via Zoom video conference for facility direct care staff, titled “Working with Difficult Behaviors.” CCLD reviewed a copy of P1’s curriculum, which consisted of a PowerPoint deck with 90 detailed slides.


[CONTINUED ON LIC 9099-C, 2 of 2]
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 05/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2024
LIC9099 (FAS) - (06/04)
Page: 7 of 8
Control Number 08-AS-20210209131152
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: DSC - VILLAGE HOUSE
FACILITY NUMBER: 370808482
VISIT DATE: 05/15/2024
NARRATIVE
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[CONTINUED FROM LIC 9099-C, 1 of 2]

CCLD either interviewed or attempted to interview every direct-care staff who worked at the facility during the allegation time frame. In available interviews, direct care staff confirmed that Licensee provided them with training pertinent to managing challenging client aggressive behaviors.

Based on interviews and records, a preponderance of evidence does not exist to prove that Licensee did not provide its direct care staff with training to meet C1’s behavioral needs. The complaint allegation is therefore Unsubstantiated, and no deficiency was cited.

An exit interview was conducted with Hollobaugh and Barber, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 05/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2024
LIC9099 (FAS) - (06/04)
Page: 8 of 8