374602496-4-24-2024-08-AS-LTEZ-D4SUXB-20240429155803

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374602496
Report Date: 04/24/2024
Date Signed: 04/24/2024 09:26:43 AM

Unsubstantiated

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
07/13/2022 and conducted by Evaluator Dang Nguyen

COMPLAINT CONTROL NUMBER: 08-AS-20220713154617

FACILITY NAME:	ROSELAND IV		FACILITY NUMBER:	374602496
ADMINISTRATOR:	LIBERTY NELSON		FACILITY TYPE:	735
ADDRESS:	117 OXFORD STREET		TELEPHONE:	(619) 691-6964
CITY:	CHULA VISTA	STATE: CA	ZIP CODE:	91911
CAPACITY:	6	CENSUS: 0	DATE:	04/24/2024
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Administrator Liberty Nelson		TIME COMPLETED:	09:30 AM

ALLEGATION(S):

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Licensee's staff physically abused client.

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 Administrator Liberty Nelson.

The Complainant alleged that Licensee’s staff physically abused a client, because on 07/12/2022, Client #1 (C1) had new cuts on some fingers of their left hand, and because C1 had some older scratch marks on their back. CCLD’s investigation involved unannounced facility tours / welfare checks on clients in care. The Department also interviewed pertinent residents, facility staff, and outside sources, and reviewed facility and outside source care records on C1.

[CONTINUED ON LIC 9099-C,1 of 2]

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang Nguyen	TELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:	DATE: 04/24/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2024

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 3

Control Number 08-AS-20220713154617

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: ROSELAND IV	FACILITY NUMBER: 374602496
	VISIT DATE: 04/24/2024

NARRATIVE

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[CONTINUED FROM LIC 9099]

According to C1’s latest San Diego Regional Center (SDRC) Individual Program Plan (IPP) (dated 05/21/2019): C1’s baseline behaviors consisted of “hitting, pushing, self-injurious behaviors, [and] emotional outbursts.” The outbursts “occur when [C1 is] frustrated and unable to communicate [their] wants,” and manifest in C1 biting or hitting themselves. One of C1’s formal IPP goals was to reduce the frequency of self-injurious behaviors “from thirteen times monthly to eight times monthly or less.” C1 was also known to suck on their thumb (even when they were calm). SDRC’s Level 4 Transition Form (dated 09/17/2012) showed that C1’s hitting and biting themselves were long-standing (not new) behaviors.

A Quarterly Behavioral Summary report (dated 05/08/2022), written by a third-party psychiatrist assigned to C1, reiterated that C1 showed “temper outbursts, physical aggression, [and] self-injurious behaviors,” among other behaviors. The report further mentioned that three months prior to 05/08/2022, C1 had a goal of reducing the frequency of their self-injurious behavior from 30 times per month to 15 times per month. However, C1 fell short of meeting this goal during said review period.

Interviews of pertinent facility staff and SDRC staff, E-mail between Licensee and SDRC, and handwritten progress notes aligned to show: Around 11:00 PM on 07/11/2022, a facility caregiver entered C1’s bedroom to assist their roommate, Client #2 (C2), to the toilet. While this occurred, C1 woke up and became upset at being woken, but staff were able to redirect them to go back to sleep. At about 4:00 AM on 07/12/2022, the caregiver entered to assist C2 to the toilet again; this time, C1 remained asleep. Around 7:30 AM later that same morning, another caregiver was assisting C1 in the shower when they noticed two new bite marks on C1’s left thumb and one new bite mark on C1’s left ring finger. Facility staff applied basic first aid to the affected areas on C1’s fingers and timely notified C1’s SDRC social worker, primary care physician (PCP), and day program staff (where C1 attended later that same day). Facility staff followed PCP instructions and continued to observe C1’s hand over the next few days; it healed without any sign of infection or need for medical care beyond basic first aid.

[CONTINUED ON LIC 9099-C, 2 of 2]

SUPERVISOR'S NAME: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang Nguyen	TELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:	DATE: 04/24/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 08-AS-20220713154617

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: ROSELAND IV	FACILITY NUMBER: 374602496
	VISIT DATE: 04/24/2024

NARRATIVE

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[CONTINUED FROM LIC 9099-C, 1 of 2]

Per facility manager interview: The scratches on C1’s back were closed/dry marks that seemed to already be healing by 07/12/2022 (this was corroborated by ADP staff interview). C1 was known to either scratch their back or brush their body up against hard surfaces, such as walls or door posts. Per SDRC interview: On 07/20/2022, a SDRC social worker visited the facility to investigate the incident. During this visit, they witnessed C1 trying to bite their own hands; facility staff quickly redirected C1 to stop. SDRC indicated that C1 had callouses on their hands due to the frequency of past self-injurious behavior.

For the current incident in question, there were no witnesses as to how C1 sustained these latest injuries. On 07/27/2022, with C1’s cooperation, a CCLD Investigator photographed C1’s left hand and back. The injuries observed on C1’s hand was consistent with a biting explanation. The injuries observed on C1’s back was consistent with a scratching explanation. CCLD attempted to interview C1 about the origin of their latest injuries, but C1 was not able speak. [C1’s latest LIC602 Physician’s Report (dated 03/25/2022) confirmed that C1 was baseline “non-verbal” and unable to communicate.] However, CCLD successfully interviewed C2 (the roommate of C1), who said that facility staff do not hit clients and are “nice” to them.

Based on interviews and records, a preponderance of evidence does not exist to prove the Licensee’s staff physically abused a client in care. The allegation is therefore Unsubstantiated.

An exit interview was conducted with Nelson, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.

SUPERVISOR'S NAME: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang Nguyen	TELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:	DATE: 04/24/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2024

LIC9099 (FAS) - (06/04)

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