374603596-10-31-2022-08-AS-SJAB-CKR28L-20221031171030

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374603596
Report Date: 10/27/2022
Date Signed: 10/31/2022 04:26:11 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
08/22/2022 and conducted by Evaluator Debbie Correia

COMPLAINT CONTROL NUMBER: 08-AS-20220822105024

FACILITY NAME:	PEOPLE'S CARE JOHNSON LAKE		FACILITY NUMBER:	374603596
ADMINISTRATOR:	PERONA REYES, LISA		FACILITY TYPE:	735
ADDRESS:	11691 JOHNSON LAKE DR		TELEPHONE:	(619) 390-1380
CITY:	LAKESIDE	STATE: CA	ZIP CODE:	92040
CAPACITY:	4	CENSUS: 4	DATE:	10/27/2022
		UNANNOUNCED	TIME BEGAN:	04:30 PM
MET WITH:	Caregiver, Lana Lamont		TIME COMPLETED:	05:45 PM

ALLEGATION(S):

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Staff restrained and pushed client resulting in injury.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Debbie Correia conducted an unannounced visit to deliver investigated findings on the above-mentioned allegation. LPA identified herself and discussed the purpose of the visit and the elements of the allegations with Caregiver Lana Lamont.

The Department’s investigation consisted of staff, client, and outside source interviews. It also consisted of a facility records review.

It was alleged when Client1 (C1) attempted to AWOL from the facility the staff restrained C1 causing an injury to C1. An interview with an Outside Source (OS1) revealed C1 disclosed they attempted to elope from the facility and was restrained by facility Staff1 (S1) and Staff2 (S2) and was dragged across the area surrounding the front of the facility that left a bruise on C1’s back. OS1 also revealed C1’s story changed regarding the area staff dragged C1 from and where they were dragged to. Interviews with S1 and S2 corroborated that C1 attempted to elope from the facility, the interview also revealed C1 tried to elope through a gate that led to a street with on-coming traffic.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Debbie Correia
LICENSING EVALUATOR SIGNATURE:	DATE: 10/27/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2022

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-20220822105024

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: PEOPLE'S CARE JOHNSON LAKE	FACILITY NUMBER: 374603596
	VISIT DATE: 10/27/2022

NARRATIVE

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S1 and S2 tried to talk to C1 to re-direct them back to the facility but C1 began to fight and grabbed S2 by their clothing and dropped to the ground landing on their back and pulled S2 down too. C1 continued to punch, kick, and pull S2’s hair. S1 and S2 implemented a CPI restraint until they were able to calm C1 down and then escorted them back to the facility, C1 then retreated to their bedroom. A facility records review revealed facility staff were trained on how to properly conduct a CPI restraint at the time of hire and have attended an additional training since the incident occurred.

An interview with another Staff3 (S3), that has worked at the facility since before C1 moved in, revealed C1 had recently talked about wanting to move to a new facility because they had lived at this facility for so long they wanted a change The interview also revealed C1 has a history of AWOL attempts and making false allegations when they do not get their way. An interview with another Outside Source (OS2) revealed an interview with C1 changed from what they previously reported, and matched what S1 and S2 said happened.

Based on LPA’s observations, records review, and interviews conducted with clients, staff, and outside sources the above allegation was determined to be unsubstantiated. An unsubstantiated finding means although the allegation may have occurred the preponderance of the evidence standard has not been met.

An exit interview was conducted with Caregiver Lamont and a copy of this report along with Licensee/Appeal Rights (LIC 9058 01/16) was provided . Signature of this form confirms receipt the documents were received.

SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Debbie Correia
LICENSING EVALUATOR SIGNATURE:	DATE: 10/27/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2022

LIC9099 (FAS) - (06/04)

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