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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374603818
Report Date: 05/26/2023
Date Signed: 05/26/2023 03:09:04 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
05/24/2023 and conducted by Evaluator Tiffany Holmes
COMPLAINT CONTROL NUMBER: 08-AS-20230524143948
FACILITY NAME:EUBANK CASTLEFACILITY NUMBER:
374603818
ADMINISTRATOR:ANETA STANEK DE LAFACILITY TYPE:
735
ADDRESS:1528 SANGAMON AVENUETELEPHONE:
(619) 825-6473
CITY:SPRING VALLEYSTATE: CAZIP CODE:
91977
CAPACITY:6CENSUS: 4DATE:
05/26/2023
UNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Monica Mc Dade, Program ManagerTIME COMPLETED:
03:20 PM
ALLEGATION(S):
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Staff hit resident
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA)Tiffany Holmes conducted an unannounced complaint visit to the facility to deliver findings on the above-mentioned allegations. LPA gained access to the facility, identified herself, and met with Monica Mc Dade, Program Manager to discuss the purpose of the visit. LPA’s visit consisted of delivering findings on the above-mentioned allegation.

LPA conducted a physical inspection of the facility, collected relevant records, and conducted interviews with clients, facility staff, and outside sources. It was alleged that staff hit resident. Interviews revealed on May 24/2023, Client 1 (C1) had a verbal altercation with Staff 1 (S1). During the verbal altercation, S1 threw a can of Red Bull at C1's face, thus resulting in the C1 sustaining one lacerations on their face. C1 has a laceration above their lip. The Program Manager terminated S1 from employment at the facility immediately after the incident.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Tiffany Holmes
LICENSING EVALUATOR SIGNATURE:

DATE: 05/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2023
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 3
Control Number 08-AS-20230524143948
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: 05/26/2023
NARRATIVE
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Interviews revealed that emergency services were called (911) and C1 was taken to the hospital and seen and treated and C1 was given a topical glue to close the laceration to their lip.

Based on the evidence obtained from interviews, records review, the complaint allegation is found to be substantiated; as the preponderance of evidence proves the alleged violation occurred.

An exit interview was conducted with Monica MC Dade, Program Manager and a copy of this report along with Licensee/Appeal Rights (LIC 9058 03/22) was provided at the conclusion of the visit.
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Tiffany Holmes
LICENSING EVALUATOR SIGNATURE:

DATE: 05/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/25/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 08-AS-20230524143948
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/26/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/12/2023
Section Cited
CCR
80072(a)(3)
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Personal Rights: (a) Except for children’s residential facilities, each client shall have personal rights which include, but are not limited to, the following:To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse, or other actions of a punitive nature, including but not limited to: interference with the daily living functions, including eating, sleeping, or toileting; or wThis requirement is not met as evidenced by:ithholding of shelter, clothing, medication or aids to physical functioning.
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Licensee terminated staff on 05/24/2023 to remove the immediate threat. Licensee will also provide training to staff on June 10, 2023 & training topics will be Behavior Interventions/ De-escalation Strategies & Signs of Staff Burnout by a behavior consultant. POC due is 06/12/203
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On May 24, 2023 1 out of 4 clients were injured by Staff 1 when they threw a can of red bull at C1 and hit them in the face causing 1 laceration on C1s face. This poses an immediate health and safety risk to clients in care.
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Licensee will submit training materials & signatures of staff signin sheets to CCL by POC date of 06/12/2023
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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: Simon Jacob
LICENSING EVALUATOR NAME: Tiffany Holmes
LICENSING EVALUATOR SIGNATURE:

DATE: 05/26/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3