374603352-2-22-2023-18-AS-JDHS-CS7UUC-20230526155319

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374603352
Report Date: 02/22/2023
Date Signed: 02/22/2023 02:12:21 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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/15/2023 and conducted by Evaluator Stephanie Torres

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20230215150027

FACILITY NAME:	MOUNTAIN SHADOWS OUTREACH SERVICES		FACILITY NUMBER:	374603352
ADMINISTRATOR:	FLOR ANGEL REAL		FACILITY TYPE:	775
ADDRESS:	970 LOS VALLECITOS BLVD, 140		TELEPHONE:	(760) 743-3714
CITY:	SAN MARCOS	STATE: CA	ZIP CODE:	92069
CAPACITY:	150	CENSUS: 112	DATE:	02/22/2023
		UNANNOUNCED	TIME BEGAN:	09:35 AM
MET WITH:	Flor Angel Real, Program Director		TIME COMPLETED:	02:20 PM

ALLEGATION(S):

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Staff failed to meet reporting requirements following a client on client incident.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA), Stephanie Torres, conducted an unannounced visit to the facility to initiate the investigation into the above allegation. The LPA met with Flor Angel Real, Program Director, and informed her of the purpose of the visit.

A report was received by the Department alleging the facility did not report to appropriate parties following a client on client incident. It was reported Client One (C1) was bit by Client Two (C2) on or around February 14, 2023. The LPA conducted staff/client interviews, reviewed records, and took copies of relevant documentation. Staff interviews confirmed an incident did take place between C1 and C2; it was reported C1 was observed to have their fingers in C2's mouth and, after staff intervened, C1's index finger was observed to be bleeding. It was also reported C1 was observed to have made a groaning noise following the incident. An interview was attempted with C1 and C2; however, statements could not be obtained. Staff interviews revealed the incident was reported to regional center, C1's family member, and C1's primary physician by the client's residential care facility. Per Day Program staff, a call was made to Community Care Licensing (CCL) on February 16, 2023 to

Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: Deborah Mullen
LICENSING EVALUATOR NAME: Stephanie Torres
LICENSING EVALUATOR SIGNATURE:	DATE: 02/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/22/2023

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 18-AS-20230215150027

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: MOUNTAIN SHADOWS OUTREACH SERVICES	FACILITY NUMBER: 374603352
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/22/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 03/08/2023 Section Cited CCR 82061(a)(1)(D)	1 2 3 4 5 6 7	REPORTING REQUIREMENTS: (a) Upon the occurrence...of any of the events specified in Section 82061(a)(1), a report shall be made to the licensing agency... In addition, a written report ...shall be submitted...within 7 days following the occurrence of the event. (1) Events reported shall include, but not be	1 2 3 4 5 6 7	The Program Director stated a statement of certification will be submitted indicating reporting requirements were reviewed and understood.
	8 9 10 11 12 13 14	limited to...: (D) Any unusual incident which threatens the physical/ emotional health or safety of any client...This requirement wasn't met, as evidenced by: based on interviews the incident was not reported by the day program to appropriate parties. This posed a potential threat to the client in care.	8 9 10 11 12 13 14
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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: Deborah Mullen
LICENSING EVALUATOR NAME: Stephanie Torres
LICENSING EVALUATOR SIGNATURE:	DATE: 02/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/22/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 18-AS-20230215150027

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: MOUNTAIN SHADOWS OUTREACH SERVICES	FACILITY NUMBER: 374603352
	VISIT DATE: 02/22/2023

NARRATIVE

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obtain assistance on whether the incident needed to be reported. According to Program Director, Flor, the incident was not reported in writing by the day program to any agencies, responsible party or physician. An interview revealed C1 did receive medical treatment, including medication, as a result of the incident. Therefore, based on interviews, this allegation is deemed SUBSTANTIATED. A finding that the complaint is substantiated means the allegation is valid because the preponderance of the evidence standard has been met. A citation will be issued in accordance with the California Code of Regulations (Title 22, Division 6, Chapter 3).

An exit interview was conducted with Flor; this report was reviewed and a copy was provided along with appeal rights.

SUPERVISORS NAME: Deborah Mullen
LICENSING EVALUATOR NAME: Stephanie Torres
LICENSING EVALUATOR SIGNATURE:	DATE: 02/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/22/2023

LIC9099 (FAS) - (06/04)

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