374603818-9-13-2023-08-AS-DPOL-CX6KS8-20231101080908

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374603818
Report Date: 09/13/2023
Date Signed: 09/13/2023 02:16:20 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 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
09/07/2023 and conducted by Evaluator Tiffany Holmes

COMPLAINT CONTROL NUMBER: 08-AS-20230907164125

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:	09/13/2023
		UNANNOUNCED	TIME BEGAN:	12:25 PM
MET WITH:	Monica McDade, Program Administrator		TIME COMPLETED:	02:37 PM

ALLEGATION(S):

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Staff handled resident in a rough manner resulting in an injury.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Tiffany Holmes conducted an unannounced visit to initiate a complaint investigation regarding the above-mentioned allegations. LPA identified herself and met with Monica McDade, Program Adminstrator, to discuss the purpose of the visit and elements of the complaint.

It was alleged that staff handled resident in a rough manner resulting in an injury. The Department's investigation included interviews, review of pertinent records, and a review of the video recording of the incident. On Septemeber 6, 2023 Staff 1 (S1) grabbed Client 1 (C1) by the neck and also pinched C1 under the arm. Interviews revealed the staff nor the client did not make mention of the incident to Program Administrator. On September 8, 2023 the Behavior Consultant came to the facility to conduct their assessments. While doing so, C1 told them what happened two days prior. Once C1 made mention of what happened they called the Program Administrator and notified them of the situation. Interviews revealed once the Program Administrator was made aware of the incident they replayed the cameras and saw the video of the incident take place. On September 12, 2023 S1 was terminated by telephone.

An exit interview was conducted with Monica McDade, Program Administrator. A copy of this report and Licensee's Rights (LIC 9058 03/22) were provided and their signature on this report confirms receipt of the Licensee Rights.

**Civil penalties in the amount of $1000 are being assessed today during this visit for a repeat violation from 05/26/2023 **

Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Tiffany Holmes
LICENSING EVALUATOR SIGNATURE:	DATE: 09/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2023

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-20230907164125

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: EUBANK CASTLE	FACILITY NUMBER: 374603818
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/13/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 09/21/2023 Section Cited CCR 80072(a)(3)	1 2 3 4 5 6 7	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; This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Licensee terminated staff on 09/12/23 to remove the immediate threat. Licensee will also provide training to staff by 09/21/23 on No restraints in the facilityt by a behavior consultant. POC due is 09/21/203
	8 9 10 11 12 13 14	On 9/6/23 1 out of 5 clients were injured by Staff 1 when they grabbed C1 by the neck and pinched them on their arm.This poses an immediate health and safety risk to clients in care.	8 9 10 11 12 13 14	Licensee will submit training materials & signatures of staff signin sheets to CCL by POC date of 09/21/2023
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Denise Powell
LICENSING EVALUATOR NAME: Tiffany Holmes
LICENSING EVALUATOR SIGNATURE:	DATE: 09/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2023

LIC9099 (FAS) - (06/04)

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