374603857-10-5-2022-08-AS-JRAE-CLNRG2-20221130120000

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374603857
Report Date: 10/05/2022
Date Signed: 10/05/2022 12:27:31 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
09/28/2022 and conducted by Evaluator Tiffany Holmes

COMPLAINT CONTROL NUMBER: 08-AS-20220928084803

FACILITY NAME:	OPEN ARMS II ADULT RESIDENTIAL FACILITY		FACILITY NUMBER:	374603857
ADMINISTRATOR:	WATKINS, JERRY		FACILITY TYPE:	735
ADDRESS:	9515 DATE ST.		TELEPHONE:	(619) 368-0626
CITY:	SPRING VALLEY	STATE: CA	ZIP CODE:	91977
CAPACITY:	6	CENSUS: 6	DATE:	10/05/2022
		UNANNOUNCED	TIME BEGAN:	08:05 AM
MET WITH:	Ethel Gray, Facility Manager		TIME COMPLETED:	09:52 AM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Unlawful Eviction

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Tiffany Holmes conducted an unannounced investigation visit to open a complaint investigation regarding the above mentioned allegation. LPA was granted entry and met with Facility Manager Ethel Gray. Administrator Yadira Watkins arrived during the visit. We discussed the purpose of the visit and elements of the complaint allegation.

During the visit, LPA toured the facility, reviewed and obtained copies of facility records. It was alleged that the facility provided an unlawful eviction to a client in care. Interviews revealed the resident went to the hospital on September 26, 2022 after the Sheriff's were called due to an altercation C1 was involved in with another client. The sherrif's deputy arrested C1 and transported them to the hospital. Interviews revelaed when C1 was ready to be discharged,

Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Tiffany Holmes
LICENSING EVALUATOR SIGNATURE:	DATE: 09/30/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2022

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-20220928084803

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: OPEN ARMS II ADULT RESIDENTIAL FACILITY	FACILITY NUMBER: 374603857
	VISIT DATE: 10/05/2022

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

the administrator advised the hospital they would not accept C1 back in the facility at this time due to the facility waiting on CCLs response to the 3 day eviction. C1 returned to the facility on September 29, 2022 and staff have had a one on one caregiver for C1 since their return.

We have found there is a preponderance of evidence to prove the alleged violation occurred and is therefore determined to be substantiated. This deficiency has been cited per Title 22 Regulations and is listed on page 2 of this report.

An exit interview was conducted with Facility Manager, Ethel Gray. A copy of this report and the Licensee's Rights (LIC9058 01/16) were provided to manager, at the conclusion of the visit.

SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Tiffany Holmes
LICENSING EVALUATOR SIGNATURE:	DATE: 09/30/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 08-AS-20220928084803

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: OPEN ARMS II ADULT RESIDENTIAL FACILITY	FACILITY NUMBER: 374603857
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/05/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 10/06/2022 Section Cited CCR 80068.5(b)	1 2 3 4 5 6 7	Eviction Procedures:The licensee shall obtain prior written approval from the Department to evict the client upon three (3) days written notice to quit and upon a finding of good cause.	1 2 3 4 5 6 7	The licensee will develop written eviction procedures for the facility in accordance with Title 22 regulations. This document is due to CCL by 10/06/2022. The Licensee will have training on 10/25/22 by Flex Ed on Assaultive Beahvior Management.The Licensee will submit the training documents and sign in sheet by 10/26/2022 for the training.
	8 9 10 11 12 13 14	Based on facility documents, and outside witness statements, the Licensee failed to accept back client from hospital when clients discharge was ready.3-Day Eviction Request submitted by the Licensee and responded to by the Department that was denied This poses a potential health risk to clients in care.	8 9 10 11 12 13 14
	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: Simon Jacob
LICENSING EVALUATOR NAME: Tiffany Holmes
LICENSING EVALUATOR SIGNATURE:	DATE: 09/30/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2022

LIC9099 (FAS) - (06/04)

Page: 3 of 3