374603818-7-20-2023-08-AS-DPOL-CU9R9S-20230731125003

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374603818
Report Date: 07/20/2023
Date Signed: 07/20/2023 05:04:37 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
06/27/2023 and conducted by Evaluator Tiffany Holmes

COMPLAINT CONTROL NUMBER: 08-AS-20230627151840

FACILITY NAME:	EUBANK CASTLE		FACILITY NUMBER:	374603818
ADMINISTRATOR:	ANETA STANEK DE LA		FACILITY TYPE:	735
ADDRESS:	1528 SANGAMON AVENUE		TELEPHONE:	(619) 825-6473
CITY:	SPRING VALLEY	STATE: CA	ZIP CODE:	91977
CAPACITY:	6	CENSUS: 5	DATE:	07/20/2023
		UNANNOUNCED	TIME BEGAN:	01:08 PM
MET WITH:	Monica McDade, Program Administrator.		TIME COMPLETED:	01:35 PM

ALLEGATION(S):

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Staff did not intervene in resident on resident altercation

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Tiffany Holmes conducted a complaint visit to close out the investigation. LPA was greeted at the front door by Monica McDade, Program Administrator and granted entry after identifying herself and disclosing the reason for her visit.

It was alleged that staff did not intervene in resident on resident altercation. Interviews revealed there was an incident between Client 1(C1) and Client 2 (C2) on 06/18/2023. Interviews revealed that C1 was upset about staff telling them they could not order a pizza and started a behavior. C2 wanted to leave and get away from C1 so the staff called the other facility and asked staff to pick C2 up. Staff came and picked up C2 while C1 was still having their behavior.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Simon Jacob	TELEPHONE: (619) 767-2301
LICENSING EVALUATOR NAME: Tiffany Holmes	TELEPHONE: (619) 481-0843
LICENSING EVALUATOR SIGNATURE:	DATE: 07/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2023

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 08-AS-20230627151840

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: EUBANK CASTLE	FACILITY NUMBER: 374603818
	VISIT DATE: 07/20/2023

NARRATIVE

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C2 ended up going to the park with the staff and before returning home, stopped at Little Caesar's and got a personal pizza. Once C2 walked into the facility and C1 saw that they had pizza C1 started up again with their behavior. Interviews revealed C2 put the pizza on the counter and started walking up the stairs to go to their room. C1 then picked up the plate the pizza was on and threw it at C2 and also threw a cup. Staff was standing at the end of the counter in between the two clients to prevent them from being close to one another. C2 started to come back down the stairs and once at the bottom of the stairwell C2 missed the last step and fell. Interviews did not reveal that staff did not intervene in resident on resident altercation.

Allegation of staff did not intervene in resident on resident altercation is unsubstantiated. An exit interview was conducted with Monica Mcdade, Program Administrator. A copy of this report and Licensee Appeal

SUPERVISOR'S NAME: Simon Jacob	TELEPHONE: (619) 767-2301
LICENSING EVALUATOR NAME: Tiffany Holmes	TELEPHONE: (619) 481-0843
LICENSING EVALUATOR SIGNATURE:	DATE: 07/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2023

LIC9099 (FAS) - (06/04)

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