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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374601939
Report Date: 03/29/2023
Date Signed: 03/29/2023 05:43:05 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
03/20/2023 and conducted by Evaluator Esther Miller
PUBLIC
COMPLAINT CONTROL NUMBER: 08-AS-20230320151741
FACILITY NAME:SPECIAL FRIENDS-SAGEWOODFACILITY NUMBER:
374601939
ADMINISTRATOR:WOJCIECHOWSKI, MICHELLEFACILITY TYPE:
735
ADDRESS:13411 SAGEWOOD DRIVETELEPHONE:
(858) 312-1687
CITY:POWAYSTATE: CAZIP CODE:
92064
CAPACITY:6CENSUS: 6DATE:
03/29/2023
UNANNOUNCEDTIME BEGAN:
12:02 PM
MET WITH:Katherine Carver, House ManagerTIME COMPLETED:
02:14 PM
ALLEGATION(S):
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Facility did not keep cleaning solution inaccessible to clients.
Facility kept expired food in refrigerator.
Facility did not keep complete medical records for clients.
Facility did not keep receipts for client purchases.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Esther Miller conducted an unannounced visit to commence a complaint investigation. LPA was granted entry by Katherine Carver, House Manager, after identifying herself. LPA discussed the purpose of the visit and the basic elements of the allegations mentioned above with House Manager. During today's visit, LPA interviewed staff and obtained records. Michelle Wojciechowsky, Administrator, arrived during the visit. At the end of the visit, LPA made a determination of findings and delivered them to House Manager.

On March 20, 2023, it was alleged that the facility did not keep cleaning solution inaccessible to clients, the facility had expired food in the fridge, did not keep complete medical records, and did not keep receipts for purchases. The Department’s investigation consisted of review of facility records, and

[Continued on LIC9099-C, Page 1 of 3]
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Esther Miller
LICENSING EVALUATOR SIGNATURE:

DATE: 03/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2023
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 5
Control Number 08-AS-20230320151741
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: SPECIAL FRIENDS-SAGEWOOD
FACILITY NUMBER: 374601939
VISIT DATE: 03/29/2023
NARRATIVE
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interviews with facility staff and outside sources.

On March 20, 2023, San Diego Regional Center submitted to the Department a Title 17 Monitoring Report conducted on March 14, 2023. Report indicated that a spray bottle containing bleach water was was observed on top of the kitchen sink. During LPA’s visit on March 29, 2023, LPA did not observe any cleaning products readily accessible to clients. LPA spoke with House Manager that confirmed that there was a spray bottle containing diluted bleach on the kitchen sink on March 20, 2023. House Manager stated that the bottle contained a very diluted solution of bleach water for cleaning.

It was further alleged that facility kept expired food in the refrigerator. Title 17 Monitoring Report indicated that a “substantial amount of expired food” was disposed of. San Diego Regional Center Coordinator (SDRCC) who wrote the report indicated that they saw mold on some of the foods. They also stated that, after disposing of the expired food, there was still an adequate amount of food for clients. House Manager confirmed that there was expired food in the refrigerator on March 20, 2023 and that it was disposed of. LPA did not observe any stored expired food items and observed adequate amount of food for clients.

It was also alleged that facility did not keep complete medical records. Title 17 Monitoring Report indicated that medication records were incomplete for eye drops belonging to Client 1 (C1 - See LIC811 Confidential Names). SDRCC revealed that medication specifically did not have a prescription. House Manager stated that the medication was obtained by C1’s parents during a one week period of time, around the end of January 2023, when C1 was staying with their parents. Upon C1’s return to the facility, parents brought C1’s medication without documentation. House Manager stored the medication in a locked cabinet around early February 2023.

It was also alleged that facility did not keep receipts for client purchases. Title 17 Monitoring Report indicated that records indicated current balance, income, and expenditures. However, records were missing receipts for purchases. House Manager explained Staff 1 (S1 - See LIC811 Confidential Names), who was assigned caregiver for outings, was not keeping receipts. LPA observed receipts dating back as far as March 23, 2023. House Manager stated they had only just began keeping receipts.

[Continued on LIC9099-C, Page 2 of 3]
SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Esther Miller
LICENSING EVALUATOR SIGNATURE:

DATE: 03/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 08-AS-20230320151741
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: SPECIAL FRIENDS-SAGEWOOD
FACILITY NUMBER: 374601939
VISIT DATE: 03/29/2023
NARRATIVE
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Based on the evidence obtained during the complaint investigation, the allegation that facility did not keep cleaning solution inaccessible to clients, the facility had expired food in the fridge, did not keep complete medical records, and did not keep receipts for purchases is found to be SUBSTANTIATED, as there is a preponderance of evidence to show that the violation occurred. Pursuant to the California Code of Regulations, Title 22, Division 6, deficiencies are being cited on the attached LIC9099D and a plan of correction was jointly developed with Christopher Carver, caregiver. An exit interview was conducted with House Manager; a copy of this report and Licensee's Rights (LIC9058) were provided. After the exit interview, House Manager had to leave the facility due to a prior engangement. POC was discussed over the phone with House Manager and caregiver.


[Continued from LIC9099-C, Page 3 of 3]
SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Esther Miller
LICENSING EVALUATOR SIGNATURE:

DATE: 03/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 08-AS-20230320151741
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: SPECIAL FRIENDS-SAGEWOOD
FACILITY NUMBER: 374601939
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/29/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/14/2023
Section Cited
CCR
80087(g)
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BUILDINGS AND GROUNDS. (g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.
This requirement is not met as evidenced by:
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House Manager offered to provide in-service training to all staff regarding proper storage of disinfectant. Proof of training will be provided to Community Care Licensing.
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Based on interviews and record reviews, the licensee did not keep clean solution inaccessible to clients which posed a health risk to residents in care.
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Type B
04/14/2023
Section Cited
CCR
80076(a)(1)
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FOOD SERVICES. (a) In facilities providing meals to clients, the following shall apply: (1) All food shall be safe and of the quality and in the quantity necessary to meet the needs of the clients. This requirement is not met as evidenced by:
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House Manager agreed to provide a written policy on how often food should be checked and by who. House Manager also offered to provide in-service training to all staff regarding proper storage of disinfectant. Proof of training will be provided to Community Care Licensing.
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Based on interviews and record reviews, the licensee did not ensure that all food was safe and in the quality necessary to meet client needs which posed a personal rights and health risk to residents 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: Denise Powell
LICENSING EVALUATOR NAME: Esther Miller
LICENSING EVALUATOR SIGNATURE:

DATE: 03/29/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 08-AS-20230320151741
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: SPECIAL FRIENDS-SAGEWOOD
FACILITY NUMBER: 374601939
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/29/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/14/2023
Section Cited
CCR
80075(k)(7)
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HEALTH RELATED SERVICES. (k) The following requirements shall apply to medications which are centrally stored: (7) The licensee shall ensure the maintenance, for each client, of a record of centrally stored prescription medications ...This requirement is not met as evidenced by:.
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House Manager agreed to obtain prescription for C1's medication. House Manager also offered to provide in-service training to all staff regarding storing and destroying medication. Proof of training will be provided to Community Care Licensing.
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Based on interviews and record reviews, the licensee did not keep record of centrally stored medication which posed a personal rights and health risk to residents in care.
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Type B
04/14/2023
Section Cited
CCR
80026(h)(1)
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SAFEGUARDS FOR CASH RESOURCES. (h) Each licensee shall maintain accurate records of accounts of cash resources... (1) ...Supporting receipts for purchases shall be filed in chronological order. This requirement is not met as evidenced by:
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House Manager offered to provide in-service training to all staff regarding record keeping of cash resources. Proof of training will be provided to Community Care Licensing.
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Based on interviews and record reviews, the licensee did not keep receipts of client purchases which posed a personal rights risk to residents 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: Denise Powell
LICENSING EVALUATOR NAME: Esther Miller
LICENSING EVALUATOR SIGNATURE:

DATE: 03/29/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5