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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374603968
Report Date: 01/12/2023
Date Signed: 01/12/2023 03:17:49 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
02/22/2022 and conducted by Evaluator Marisol Lopez
COMPLAINT CONTROL NUMBER: 08-CR-20220222084315
FACILITY NAME:A.B. JESSIE POLINSKY CHILDREN'S CENTERFACILITY NUMBER:
374603968
ADMINISTRATOR:ROSAS, ELIZABETHFACILITY TYPE:
721
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY:204CENSUS: 33DATE:
01/12/2023
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Alicia RogersTIME COMPLETED:
03:45 PM
ALLEGATION(S):
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Staff hit minor while in care.
INVESTIGATION FINDINGS:
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On January 12, 2023, at 2:00 pm, Licensing Program Analyst (LPA) Marisol Lopez arrived unannounced at the facility and met with Alicia Rogers Protective Services Program Manager (PSPM), of A.B. Jessie Polinsky Children’s Center, to discuss the investigative finding for the allegation noted above. On 02/23/2022 at 11:30 a.m., LPA Gloria Meza-Gonzalez conducted an unannounced initial safety inspection of the facility and no deficiencies were found at that time. The investigation consisted of confidential interviews with one facility administrator, five facility staff (S1- S5), one service worker, one of one client #1 (C1) and review of incident reports.

On 02/22/2022, the Department received an allegation that staff #1(S1) hit client #1 (C1) while in care. Confidential interviews revealed S1 hit C1 while on the playground in front of witnesses. Confidential interviews stated S1 was a contracted staff; S1 was escorted out of the facility; and S1’s supervisor was contacted to notify them S1 was not allowed to return to the facility. Confidential interviews stated C1 was evaluated by nursing and no injuries were reported during the incident. (see continuation form LIC9099-C dated 01/12/23)
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Ann ValenzuelaTELEPHONE: (951) 204-8846
LICENSING EVALUATOR NAME: Marisol LopezTELEPHONE: (619) 417-5040
LICENSING EVALUATOR SIGNATURE:

DATE: 01/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2023
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-CR-20220222084315
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: A.B. JESSIE POLINSKY CHILDREN'S CENTER
FACILITY NUMBER: 374603968
VISIT DATE: 01/12/2023
NARRATIVE
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Based on confidential interviews and records reviewed, the allegation that staff #1(S1) hit client #1 (C1) while in care is substantiated. The preponderance of evidence standard has been met. The facility is cited for violation of the California Code of Regulations, Title 22 Division Six, regulation 84072(d)(11) Personal Rights.

An exit interview was conducted, and appeal rights were reviewed with Alicia Rogers. A copy of this report, along with the LIC 811, and appeal rights were provided to Alicia Rogers, Protective Services Program Manager. A signed copy of this report will be kept in the facility file.
SUPERVISOR'S NAME: Ann ValenzuelaTELEPHONE: (951) 204-8846
LICENSING EVALUATOR NAME: Marisol LopezTELEPHONE: (619) 417-5040
LICENSING EVALUATOR SIGNATURE:

DATE: 01/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 08-CR-20220222084315
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: A.B. JESSIE POLINSKY CHILDREN'S CENTER
FACILITY NUMBER: 374603968
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/12/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/12/2023
Section Cited
CCR
84072(d)(11)
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84072(d)(11) Personal Rights.
(d) The licensee shall ensure that each child, regardless of whether the child is in foster care, is accorded the personal rights specified in Welfare and Institutions Code section 16001.9, as applicable. In addition, the licensee shall ensure that each child is accorded the following personal rights: (11) To be free from physical, sexual, emotional, or other abuse, and corporal punishment
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Per PSPM, S1 was escorted out of the facility on 02/17/22 immediately after incident and will not be allowed to return to the facility. S1 was a contracted staff. The facility will continue to require that all contracted staff never be left alone with clients.
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This requirement was not met as evidenced by:
Based on confidential interviews and records reviewed, staff #1(S1) hit client #1 (C1) while in care, which posed an immediate health, safety, and personal rights risk to clients in care.
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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.
SUPERVISOR'S NAME: Ann ValenzuelaTELEPHONE: (951) 204-8846
LICENSING EVALUATOR NAME: Marisol LopezTELEPHONE: (619) 417-5040
LICENSING EVALUATOR SIGNATURE:

DATE: 01/12/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3