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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374602881
Report Date: 06/01/2023
Date Signed: 06/01/2023 04:05:52 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
05/25/2023 and conducted by Evaluator Carmen Lopez
COMPLAINT CONTROL NUMBER: 08-AS-20230525092806
FACILITY NAME:A PLACE OF GRACE INC CANTON DRIVEFACILITY NUMBER:
374602881
ADMINISTRATOR:HAINES, SHANTAFACILITY TYPE:
735
ADDRESS:7312 CANTON DRTELEPHONE:
(619) 467-7367
CITY:LEMON GROVESTATE: CAZIP CODE:
91945
CAPACITY:6CENSUS: 3DATE:
06/01/2023
UNANNOUNCEDTIME BEGAN:
12:40 PM
MET WITH:Mary Meeter, AdministratorTIME COMPLETED:
04:15 PM
ALLEGATION(S):
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- Staff did not secure sharps
- Staff did not maintain accurate client records
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Carmen Lopez conducted an unannounced complaint visit to open a complaint investigation. While at the facility LPA investigated and delivered findings regarding the above-mentioned allegations. LPA identified herself and was granted entry by Mary Meeter, Administrator. LPA stated the purpose of the visit and reviewed the findings of the complaint with Administrator Meeter.

The Department’s investigation consisted of interviews with an outside source and staff, records review of relevant documents pertinent to this investigation, and LPA observations. On May 25, 2023, it was alleged that the facility did not secure their sharps and client records were not updated.

It was specifically alleged that the staff had their blender out in an unlocked cabinet. Interview with an outside source said that the facility had their blender in a cabinet next to the refrigerator. Once the staff were notified, they locked their blender in their closet where their sharps are kept.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Rebecca Hedgecock
LICENSING EVALUATOR NAME: Carmen Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 06/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/01/2023
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 3
Control Number 08-AS-20230525092806
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: A PLACE OF GRACE INC CANTON DRIVE
FACILITY NUMBER: 374602881
VISIT DATE: 06/01/2023
NARRATIVE
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Interview with staff #1 (S1) confirmed that they had a blender out but was locked away when they were notified it needed to be placed in a locked cabinet. On June 1, 2023, LPA toured the facility and observed that the blender was placed in a locked cabinet where their sharps were placed.

It was also specifically alleged that staff did not have updated documents in the client’s files. Interview with an outside source said that they did not have records updated in two of the client’s files. Interview with S1 said that they are currently updating client’s files. A review of records revealed that Client #1’s (C1) records did not have an updated Face Sheet (last updated October 2021), Emergency Contact Information (last updated December 2021) and did not have a Preplacement form. In review of Client #2 (C2) records revealed that they did not have an updated Face Sheet (last updated May 2021), Identification and Emergency Contact Information (last updated December 2021) and did not have a Needs and Service Plan. The records for Client #3 (C3) revealed that the facility did not have an updated Identification and Emergency Contact Information (last updated September 2021) and did not have a Preplacement form. On June 1, 2023, LPA toured the facility and observed that S1 was updating the client’s files.

Based on the Department’s investigation of the above-mentioned allegations and the evidence obtained during staff and outside source interviews, records reviewed, and LPA observations, there is sufficient evidence to meet the preponderance of evidence standard. Therefore, the above allegations are deemed to be substantiated. California Code of Regulations, Title 22, Division 6, Chapter 8, is being cited on the attached LIC9099-D.

The report was discussed, plan of correction was jointly developed, and an exit interview was conducted with Administrator Meeter. A copy of this report along with Licensee/Appeal Rights (LIC9058 3/22) were provided to Administrator Meeter at the conclusion of the visit. The signature below confirms the receipt of these documents.
SUPERVISORS NAME: Rebecca Hedgecock
LICENSING EVALUATOR NAME: Carmen Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 06/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/01/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 08-AS-20230525092806
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: A PLACE OF GRACE INC CANTON DRIVE
FACILITY NUMBER: 374602881
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/01/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/01/2023
Section Cited
CCR
80087(g)(1)
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80087 Buildings and Grounds (g)(1) Storage areas for poisons, and firearms and other dangerous weapons shall be locked. … this requirement was not met as evidence by:
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POC has been cleared.
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Based on interviews, staff did not keep the blender in a locked area. This posed a potential safety risk to 3 of 3 [C1, C2 & C3] clients in care.
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Type B
06/16/2023
Section Cited
CCR
80070(a)
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80070 Client Records (a) The licensee shall ensure that a separate, complete, and current record is maintained in the facility for each client. … this requirement was not met as evidence by:
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Administrator will be updating C1, C2 & C3's documents and submitting the documents to the LPA by POC due date.
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Based on interviews and records review, staff did not have updated client records. This posed a potential personal rights risk to 3 of 3 [C1, C2, &C3] clients 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: Rebecca Hedgecock
LICENSING EVALUATOR NAME: Carmen Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 06/01/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/01/2023
LIC9099 (FAS) - (06/04)
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