<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374603669
Report Date: 01/26/2023
Date Signed: 01/26/2023 04:46:28 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SO. CAL AC/SC, 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
08/25/2022 and conducted by Evaluator Daniel Pena
COMPLAINT CONTROL NUMBER: 08-AS-20220825154741
FACILITY NAME:HABILITATIVE HOMES RESIDENTIAL CARE FACILITYFACILITY NUMBER:
374603669
ADMINISTRATOR:DAVID LARSONFACILITY TYPE:
735
ADDRESS:11775 WALNUT ROADTELEPHONE:
(619) 270-4484
CITY:LAKESIDESTATE: CAZIP CODE:
92040
CAPACITY:6CENSUS: 6DATE:
01/26/2023
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:David Larson, AdministratorTIME COMPLETED:
04:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
-Administrator did not allow healthcare professional to obtain a urinalysis from client as ordered by a healthcare professional
-Facility staff did not seek and/or arrange medical attention for client in care
-Facility staff directed healthcare professionals to provide routine client care on the front porch and/or in a motorhome
-Facility staff did not treat client with dignity and respect
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 01/26/2023, Licensing Program Analysts (LPA) Daniel Pena and Renita Hall visited the facility regarding the aforementioned complaint allegations. LPAs introduced themselves and after displaying their identification were allowed into the facility. LPAs met with Administrator, David Larson (DL), to whom the elements of this complaint were discussed. During the visit, LPAs toured the physical plant, collected additional evidence, and discussed the findings of the investigation with Administrator Larson.

On 8/25/2022, the Department received a complaint alleging the following: Administrator did not allow a healthcare professional to enter facility and obtain a prescribed urine sample from a client in care; facility staff did not seek and/or arrange medical attention for a client in care; facility staff directed healthcare professionals to administer routine client care on the porch and/or mobile home and facility staff did not treat client in care with dignity and respect. The Department’s investigation consisted of facility visits, record reviews and interviews with clients, staff, and outside sources.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Daniel Pena
LICENSING EVALUATOR SIGNATURE:

DATE: 01/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2023
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 10
Control Number 08-AS-20220825154741
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SO. CAL AC/SC, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: HABILITATIVE HOMES RESIDENTIAL CARE FACILITY
FACILITY NUMBER: 374603669
VISIT DATE: 01/26/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
As to the allegation, the Administrator (DL) did not allow a healthcare professional to obtain a prescribed urine sample from a client in care, this investigation revealed the following. On 8/22/2022, Client 1 (C1) was visited at Habilitative Homes Residential Care Facility by Healthcare Professional 1 (HP1). During the visit, HP1 noticed C1 was walking funny and although C1 answered most questions correctly during a cognitive test, C1 answered some questions wrong. HP1 believed C1 may be experiencing a Urinary Tract Infection (UTI) and told DL they would be ordering a urine sample to check C1 for a UTI. The order was sent to C1’s home health provider that same evening and the following day (8/23/2022), Healthcare Professional 2 (HP2) went to the facility to collect the urine sample from C1. Interviews revealed that before exiting their vehicle, HP2 was contacted by Staff 2 (S2) who handed HP2 a cellular telephone. HP2 spoke to DL on the phone who told HP2 that they no longer needed to collect a urine sample from C1. HP2 said they were not given the opportunity to check on C1, so they left.

During their interview, on 8/22/2022, DL said C1 was evaluated at the facility by HP1 who did a full assessment and checked C1’s vitals which were normal. DL said HP1 performed a cognitive test on C1 and told DL that C1 was manipulating their answers and purposely answering them wrong. DL said HP1 told them that C1 was in good health. DL said they asked HP1 to collect a urine sample to check for a UTI infection. DL said HP1 told them C1 is fine, and a urine sample was not needed. Allegedly, HP1 told DL they would order the sample since it was requested.

According to DL, on 8/23/2022, at around 9:30 AM, a health care professional arrived at the facility to collect a urine sample from C1. DL told an investigator that they spoke to the health care provider via telephone before they contacted C1. DL told them C1 no longer needed a urinalysis. Investigator asked DL why they changed their mind. DL told the investigator it was because HP1 told DL that C1 was faking their condition.
However, on 8/24/2022, DL called the home health agency several times requesting a nurse to come to the facility and obtain a urine sample from C1. DL told investigators they thought about it throughout the night and decided C1 needed to be checked.

As to the allegation facility staff did not seek and/or arrange medical attention for a client in care, the investigation discovered the following. Interviews revealed that on 8/23/2022, between 7:00 and 8:00 PM, S2 passed C1’s bedroom and observed them lying on the tile floor. S2 assumed that C1 voluntarily laid on the floor because S2 did not hear a fall. S2 did not observe nor was S2 informed by anyone how C1 ended up on the floor. According to S2, C1 refused to get off the floor when asked to get up. S2 said C1 refused staff’s
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Daniel Pena
LICENSING EVALUATOR SIGNATURE:

DATE: 01/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 10
Control Number 08-AS-20220825154741
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SO. CAL AC/SC, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: HABILITATIVE HOMES RESIDENTIAL CARE FACILITY
FACILITY NUMBER: 374603669
VISIT DATE: 01/26/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
help. S2 said C1 had no obvious injuries. S2 stated that C1 remained on the floor throughout the night with staff checking on them, offering water food and trying to convince them to get up and go to bed. The following morning, DL called C1’s home health provider numerous times in the morning to request that a nurse come to the facility and evaluate C1. DL was advised by the home health provider that they did not have a nurse immediately available, and DL was advised a nurse would come to the facility around 3:00 PM to check on C1.

During DL’s interview, investigators told DL it appeared they were concerned about C1 since they called home health several times. When asked why DL did not call 911 after being advised it would be a lengthy response time, DL said they were not sure C1 was telling the truth. DL alleged that HP1 said C1 was faking symptoms. Investigators interviewed HP1 and they denied saying C1 was not telling the truth. HP1 reminded the investigator that it was they (HP1) who ordered C1’s urine sample because they were displaying UTI symptoms.

Interviews revealed that C1 was experiencing mental health or medical distress as early as 8/22/2022 when HP1 noticed C1 walking differently and displaying cognitive issues. By 8/23/2022, C1’s condition declined when they were found on the floor by staff. Healthcare Professional 3 (HP3) told investigator that they were dispatched to the facility on 8/24/22 to check on C1. HP3 informed their supervisor (HP4) that HP2 went to the facility on 8/23/2022 to obtain a urine sample and was turned away by DL. HP4 spoke with DL and asked why HP2 was refused entry. DL told HP4 that they did not believe C1 was being truthful. On 8/24/2022, DL told HP3 they would meet them at the facility but then later said they (DL) could not be there. Instead, Staff 3 (S3) met HP3 and allowed HP3 inside the facility to check C1. HP3 was escorted upstairs to C1’s bedroom and found C1 lying on the floor. HP3 conducted an assessment and noted C1 was weak, incoherent, moaning, confused and unresponsive to questions. HP3 said they had been caring for C1 for several months and determined C1 was not at baseline. HP3 asked the caregiver why they did not try to help C1 off the floor and was told, “Because they (C1) are faking.” HP3 asked the caregiver to call 911. HP3 went to their vehicle to wait until medics arrived but eventually called themselves. Interviews showed that C1 remained on the floor until HP3 came to the facility on 8/24/22 and called 911.

Interviews corroborated this information. A witness reported that C1 suffered from “bladder infections” and when they have one they, “go crazy.” Interviews also indicate that a witness walked by C1’s room to go to the bathroom and observed C1 lying on the floor. The witness said C1 was “out of it.” The witness said C1 was
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Daniel Pena
LICENSING EVALUATOR SIGNATURE:

DATE: 01/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 10
Control Number 08-AS-20220825154741
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SO. CAL AC/SC, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: HABILITATIVE HOMES RESIDENTIAL CARE FACILITY
FACILITY NUMBER: 374603669
VISIT DATE: 01/26/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
on the floor the entire day. The witness also said, later in the day, paramedics arrived, and C1 was taken to the hospital.

When C1 arrived at the hospital on 8/24/2022, they were diagnosed with UTI, severe dehydration, sepsis, and renal failure. During an interview with C1’s Primary Care Provider (PCP), they said it is common for someone in C1’s condition with a catheter to get UTIs that often turn into sepsis. During an interview with C1’s PCP, the physician said it was alarming and inhumane to leave a client on the floor for 19 – 20 hours without receiving medical treatment. The physician stated it was obvious C1 was either experiencing a medical or psychiatric condition and should have been evaluated immediately by a medical professional. Based on interviews, it is reasonable to conclude that C1’s UTI worsened because they were left on the floor for 19-20 hours and not afforded medical treatment when their symptoms first began to present themselves.

In regard to the allegation, facility staff directed healthcare professionals to administer routine client care on the porch and/or mobile home, the investigation revealed the following. HP3 told investigator that in the 5 – 6 months they had been caring for C1, DL has not allowed them into the facility to visit C1. When asked if staff provided a reason, HP3 said they always cited “Covid restrictions.” HP3 said they are vaccinated and comply with Covid protocols so they are not sure why the facility will not allow them to visit C1 inside the facility. HP3 calls ahead to notify facility staff of the date and time of a visit. If C1 requires a catheter change, staff will bring C1 to a mobile home which is parked in front of the facility. HP3 will change the catheter inside the motor home. HP3 said the atmosphere in the motorhome is not always pleasant (hot or cold) and although HP3 sanitizes themselves and equipment, HP3 could not determine the level of sanitation inside the motor home. HP3 said if C1 requires an assessment, staff will bring C1 to the front patio for evaluation.
Department Provider Information Notice (PIN) 21-17-ASC, Updated Statewide Waiver Related to Coronavirus Disease 2019 (COVID-19) and Visitation; Communal Dining; Group Activities; Non-Essential Services; Outings; and New Admissions, dated March 19, 2021, was reviewed as part of this investigation and states in part, “visitation waiver shall not apply to essential visits, which shall include the following: Medically necessary visits or other urgent health or legal matters that cannot be postponed…Visits from CDSS, CDPH, CDDS or local regional center, local health department, officials, mental/healthcare providers (e.g., home health and hospice agencies), and essential government authorities needing to enter or conduct investigations at the facility.”
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Daniel Pena
LICENSING EVALUATOR SIGNATURE:

DATE: 01/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 10
Control Number 08-AS-20220825154741
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SO. CAL AC/SC, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: HABILITATIVE HOMES RESIDENTIAL CARE FACILITY
FACILITY NUMBER: 374603669
VISIT DATE: 01/26/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
As to the allegation facility staff did not treat client with dignity and respect, this investigation revealed the following. Upon observing C1 lying on the floor, HP3 determined C1 was not at normal baseline. HP3 asked a caregiver why they did not try to help C1 off the floor. The caregiver told HP3, “Because (C1) are faking.” The caregiver told HP3 that they kept telling C1 to get up off the floor, but C1 refused. HP3 asked the caregiver why they didn’t get a co-worker to help and lift C1 from the floor. The caregiver told HP3, “we’re not going to break our backs.” HP3 told the caregiver C1 had been on the floor for over eight hours and the caregiver corrected HP3 and said C1 had been lying on the floor since the previous day (8/23/2022). HP3 asked the caregiver why they did not call 911 but the caregiver did not answer.

During their interview, Healthcare Professional 4 (HP4) said they spoke with DL by telephone on 8/24/2022. DL had called the provider office several times that morning trying to get a nurse to visit C1 at the facility. When HP4 spoke with DL, DL told them that C1 is a drug addict and the only reason they are acting this way is so they could go to the hospital and get narcotic drugs. C1’s medical records were reviewed and corroborate that this statement was made by facility staff.

Hospital records taken on 8/24/2022, indicate that hospital staff received a telephone call from facility staff requesting a healthcare professional to visit the facility and evaluate C1. When the healthcare professional arrived at the facility, C1 was observed on the floor. The record indicates that per facility staff, C1 had been on the floor since 8/23/2022, refusing to get up. The notes show that staff told hospital personnel that C1 was “faking it.” Hospital staff noted that they asked facility staff why they did not call 911 and staff had no response.

The Department has investigated the allegations that the Administrator did not allow a healthcare professional to obtain a prescribed urine sample from a client in care; facility staff did not seek and/or arrange medical attention for a client in care; facility staff directed healthcare professionals to administer routine client care on the porch and/or mobile home and facility staff did not treat client in care with dignity and respect. Based upon interviews and record reviews, the preponderance of evidence standard has been met. Therefore, the findings are determined to be Substantiated.

Deficiencies are being cited in accordance with the California Code of Regulations, Title 22, Division 6, Chapter 8, and are noted on the attached LIC9099-D. An immediate civil penalty of $500 was assessed for the following violations: Administrator did not allow a healthcare professional to enter facility and obtain a
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Daniel Pena
LICENSING EVALUATOR SIGNATURE:

DATE: 01/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 10
Control Number 08-AS-20220825154741
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SO. CAL AC/SC, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: HABILITATIVE HOMES RESIDENTIAL CARE FACILITY
FACILITY NUMBER: 374603669
VISIT DATE: 01/26/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
prescribed urine sample from a client in care; facility staff did not seek and/or arrange medical attention for a client in care; facility staff directed healthcare professionals to administer routine client care on the porch and/or mobile home and facility staff did not treat client in care with dignity and respect. At this time, per Health and Safety Code Section 1569.49, an additional civil penalty assessment is under review by the Program Administrator of the Community Care Licensing Division.

Administrator, Larson was provided a copy of the Licensee’s appeal rights (LIC9058 01/16) and their signature on this form, acknowledges receipt of these rights. An exit interview was conducted, and a copy of this report was provided to Administrator, Larson.
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Daniel Pena
LICENSING EVALUATOR SIGNATURE:

DATE: 01/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2023
LIC9099 (FAS) - (06/04)
Page: 6 of 10
Control Number 08-AS-20220825154741
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SO. CAL AC/SC, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: HABILITATIVE HOMES RESIDENTIAL CARE FACILITY
FACILITY NUMBER: 374603669
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/26/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
01/27/2023
Section Cited
CCR
85064(j)(4)
1
2
3
4
5
6
7
Administrator Qualifications and Duties…Administrator shall…provide or ensure provision of services to the clients, required by applicable law and regulation….This requirement was not met as evidenced by: Based on interviews and record reviews,
1
2
3
4
5
6
7
The licensee agreed to procure vendorized training and provide documented proof to CCLD within 24 hours (01/27/2023) and ensure 100 percent of all facility staff participate. Licensee agreed to submit a sign-in sheet to CCLD by 02/24/2023.
8
9
10
11
12
13
14
the Administrator did not allow or ensure provision of medical services, as required by Section 85064(j)(4) for 1 of 6 persons in care [C1] which posed an immediate Health, Safety risk to persons in care.
8
9
10
11
12
13
14
Request Denied
Type A
01/27/2023
Section Cited
CCR
80075(a)
1
2
3
4
5
6
7
Health Related Services…Licensee shall ensure that each client receives necessary first aid…including arrangement for and/or provision of transportation to the nearest available services. This requirement was not met as evidenced by: Based on interviews and record reviews,
1
2
3
4
5
6
7
The licensee agreed to procure vendorized training and provide documented proof to CCLD within 24 hours (01/27/2023) and ensure 100 percent of all facility staff participate. Licensee agreed to submit a sign-in sheet to CCLD by 02/24/2023.
8
9
10
11
12
13
14
Licensee did not arrange or ensure provision of transportation to the nearest medical services, as defined by Section 80075(a), for 1 of 6 clients in care [C1] which posed an immediate Health and Safety risk to persons in care.
8
9
10
11
12
13
14
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: Simon Jacob
LICENSING EVALUATOR NAME: Daniel Pena
LICENSING EVALUATOR SIGNATURE:

DATE: 01/26/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2023
LIC9099 (FAS) - (06/04)
Page: 7 of 10
Control Number 08-AS-20220825154741
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SO. CAL AC/SC, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: HABILITATIVE HOMES RESIDENTIAL CARE FACILITY
FACILITY NUMBER: 374603669
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/26/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type B
01/27/2023
Section Cited
CCR
80072(a)(2)
1
2
3
4
5
6
7
Personal Rights...each client shall have personal rights which include, but are not limited to, the following: To be accorded safe, healthful, and comfortable accommodations, furnishings…to meet his/her needs. This requirement was not met as evidenced by: Based on interviews and record
1
2
3
4
5
6
7
The licensee agreed to procure vendorized training and provide documented proof to CCLD within 24 hours (01/27/2023) and ensure 100 percent of all facility staff participate. Licensee agreed to submit a sign-in sheet to CCLD by 02/24/2023.
8
9
10
11
12
13
14
reviews, facility staff did not accord healthful and comfortable accommodations and furnishings during medical visits, as directed by Section 80072(a)(2) for 1 of 6 clients in care [C1] which posed an immediate Health and Safety risk to persons in care.
8
9
10
11
12
13
14
Request Denied
Type B
01/27/2023
Section Cited
CCR
80072(a)(1)
1
2
3
4
5
6
7
Personal Rights…Except for children’s residential facilities, each client shall have personal rights which include…(1) To be accorded dignity in his/her personal relationships with staff and other persons. This requirement was not met as evidenced by:Based on interviews and record reviews,
1
2
3
4
5
6
7
The licensee agreed to procure vendorized training and provide documented proof to CCLD within 24 hours (01/27/2023) and ensure 100 percent of all facility staff participate. Licensee agreed to submit a sign-in sheet to CCLD by 02/24/2023.
8
9
10
11
12
13
14
facility staff, did not accord dignity in his/her personal relationships with…other persons, as required by Section 80072(a)(1) for 1 of 6 clients in care [C1] which posed an immediate Personal Rights risk to persons in care.
8
9
10
11
12
13
14
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: Simon Jacob
LICENSING EVALUATOR NAME: Daniel Pena
LICENSING EVALUATOR SIGNATURE:

DATE: 01/26/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2023
LIC9099 (FAS) - (06/04)
Page: 8 of 10
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SO. CAL AC/SC, 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
08/25/2022 and conducted by Evaluator Daniel Pena
COMPLAINT CONTROL NUMBER: 08-AS-20220825154741

FACILITY NAME:HABILITATIVE HOMES RESIDENTIAL CARE FACILITYFACILITY NUMBER:
374603669
ADMINISTRATOR:DAVID LARSONFACILITY TYPE:
735
ADDRESS:11775 WALNUT ROADTELEPHONE:
(619) 270-4484
CITY:LAKESIDESTATE: CAZIP CODE:
92040
CAPACITY:6CENSUS: 6DATE:
01/26/2023
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:David Larson, AdministratorTIME COMPLETED:
04:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Client sustained injuries while in care due to neglect
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
It was also alleged, a client sustained injuries while in care due to neglect. LPAs Pena and Hall met with Administrator, David Larson and discussed the elements of this complaint. The Department’s investigation consisted of facility visits, record reviews and interviews with clients, staff, and outside sources.

A review of Client 1’s (C1) medical records included a report indicating C1 had bruising to their left cheek, forehead, shoulder, elbow, and knee. The report does not mention the severity of the bruising, possible causes of the bruising or whether the bruises were suspicious or concerning to the physician conducting the examination. In addition, there were no photographs of C1’s bruises in the medical records. A facility staff noticed a bruise on C1’s cheek on 8/24/2022. Staff was interviewed but did not know how C1 received the injury. Staff said C1 is able to bathe themselves and was fully clothed before going to the hospital, so they did not observe any other bruising on C1’s body.

Client interviews were conducted as was a medical professional. These individuals spoke with C1
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Daniel Pena
LICENSING EVALUATOR SIGNATURE:

DATE: 01/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 9 of 10
Control Number 08-AS-20220825154741
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SO. CAL AC/SC, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: HABILITATIVE HOMES RESIDENTIAL CARE FACILITY
FACILITY NUMBER: 374603669
VISIT DATE: 01/26/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
before C1 was transported to the hospital. However, neither noticed nor reported seeing any bruising on C1’s face.

The Department has investigated the allegation that a client sustained injuries while in care due to neglect. Based on the interviews and record reviews obtained during the course of the investigation, the finding is determined to be Unsubstantiated. This finding means although the allegation may have occurred or could be valid, there is not a preponderance of evidence to prove that the alleged violation occurred.

An exit interview was conducted with Administrator, Larson. A copy of this report along with Licensee/Appeal Rights (LIC 9058 01/16) were provided and Administrator, Larson’s signature on this form confirms receipt of these reports.
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Daniel Pena
LICENSING EVALUATOR SIGNATURE:

DATE: 01/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2023
LIC9099 (FAS) - (06/04)
Page: 10 of 10