374602728-4-26-2022-08-AS-IESA-CDY88S-20220429221801

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374602728
Report Date: 04/26/2022
Date Signed: 04/26/2022 05:11:33 PM

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
03/07/2022 and conducted by Evaluator Dawn Segura

COMPLAINT CONTROL NUMBER: 08-AS-20220307144429

FACILITY NAME:	RESIDENT'S PALACE, THE		FACILITY NUMBER:	374602728
ADMINISTRATOR:	PHYLLIS BOLTON		FACILITY TYPE:	735
ADDRESS:	8090 BROOKHAVEN RD		TELEPHONE:	(619) 434-9231
CITY:	SAN DIEGO	STATE: CA	ZIP CODE:	92114
CAPACITY:	4	CENSUS: 3	DATE:	04/26/2022
		UNANNOUNCED	TIME BEGAN:	02:39 PM
MET WITH:	Phyllis Bolton, Licensee		TIME COMPLETED:	02:58 PM

ALLEGATION(S):

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Lack of supervision resulted in injury to client.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Dawn Segura conducted an unannounced visit to deliver investigative findings. LPA was granted entry into the facility by Tyrone Bolton and met with Phyllis Bolton, Licensee, to whom LPA disclosed the reason for the visit.

Community Care Licensing (CCL) has investigated the above listed complaint allegation. The investigation consisted of a tour of the facility, review of facility records, review of outside source records, and interviews with staff and licensee.

It was reported to Community Care Licensing that Client 1 (C1) [LIC 811 Confidential Names List was provided to identify the client] had a fight with another client of the facility and a facility caregiver who called law enforcement. It was reported that C1 fought with law enforcement officer(s), as well, and was observed with a black eye while at a local hospital.

Unsubstantiated

Estimated Days of Completion: 0

SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dawn Segura
LICENSING EVALUATOR SIGNATURE:	DATE: 04/26/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2022

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-20220307144429

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: RESIDENT'S PALACE, THE	FACILITY NUMBER: 374602728
	VISIT DATE: 04/26/2022

NARRATIVE

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Interviews conducted and records reviewed during the investigation reflected that C1 was transported to a local hospital by law enforcement officers who responded to a call for service at the facility. Evidence also confirmed that during transport of C1, physical interactions between C1 and a responding officer occurred. Evidence clearly indicates that during the interactions, C1 was struck in the face by one of the law enforcement officers who was transporting the client. Evidence also indicates that C1 sustained a facial injury that resulted from the interactions that occurred. However, there was no evidence obtained that provided any indication that C1 fought with any facility client or was hit in the face by any of the facility’s staff. While C1 did sustain an injury in his/her face, there was not evidence to conclude that the injury was caused by any action or inaction of the licensee or facility staff.

Based upon evidence that documents that C1 was hit in the face and sustained a visible facial injury caused by a law enforcement officer and a lack of evidence to conclude that C1’s injury resulted from a lack of supervision by facility staff, the allegation is unsubstantiated. This finding means that although the allegation may have happened or may be valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

An exit interview was conducted with Phyllis Bolton, and a copy of this report and Licensee/Appeal Rights (LIC 9058) were provided to licensee at the conclusion of the visit.

SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dawn Segura
LICENSING EVALUATOR SIGNATURE:	DATE: 04/26/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2022

LIC9099 (FAS) - (06/04)

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