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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374603968
Report Date: 02/15/2023
Date Signed: 02/15/2023 05:51:24 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,
, CA
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/22/2022 and conducted by Evaluator Charmaine Linley
PUBLIC
COMPLAINT CONTROL NUMBER: 08-CR-20220822084410
FACILITY NAME:A.B. JESSIE POLINSKY CHILDREN'S CENTERFACILITY NUMBER:
374603968
ADMINISTRATOR:ROSAS, ELIZABETHFACILITY TYPE:
721
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY:204CENSUS: 27DATE:
02/15/2023
UNANNOUNCEDTIME BEGAN:
03:50 PM
MET WITH:Elizabeth Rosas, Protective Services Program ManagerTIME COMPLETED:
04:20 PM
ALLEGATION(S):
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Facility night staff does not provide adequate supervision to youths in care.
INVESTIGATION FINDINGS:
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On February 15, 2023, at 3:50 pm, Licensing Program Analyst (LPA) Charmaine Linley arrived unannounced at the facility and met with Elizabeth Rosas, Protective Services Program Manager, of A.B. Jessie Polinsky Children’s Center, to discuss the investigative finding for the allegation noted above. LPA’s Carol Anderson and Lucero Jauregui conducted an inspection of the facility on 08/26/2022 at 10:01 am and no deficiencies were found. LPA Linley interviewed one client (C2), attempted to interview two clients (C1, C3), however was unable to interview them despite multiple attempts to contact them, interviewed twelve staff (S1-12), attempted to interview (S13, S14) however was unable to interview them despite multiple attempts to contact them, interviewed one County Social Worker (CSW1), one Mental Health Associate (MHA1), and was unable to interview (MHA2, MHA3), despite multiple attempts to contact them. During the investigation, LPA Linley reviewed the following documents: Unit Roster, Daily Staffing Worksheets, Overnight room checks, Copies of the cottage log "redbook", C1 Child History Report Summary, and C1 Needs and Services Plan.
***CONTINUED ON NEXT PAGE

Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Ann ValenzuelaTELEPHONE: (951) -782-4968
LICENSING EVALUATOR NAME: Charmaine LinleyTELEPHONE: 951-202-1850
LICENSING EVALUATOR SIGNATURE:

DATE: 02/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2023
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-20220822084410
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
FACILITY NAME: A.B. JESSIE POLINSKY CHILDREN'S CENTER
FACILITY NUMBER: 374603968
VISIT DATE: 02/15/2023
NARRATIVE
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On 08/22/2022, Community Care Licensing received an allegation that facility night staff does not provide adequate supervision to youths in care. It was reported that a non-dependent male was brought into the cottage and spent the night in the cottage. Confidential interviews confirmed that a male that was not a client of the facility spent the night in the cottage.

Based on confidential interviews and records reviewed, the allegation that facility night staff does not provide adequate supervision to youths 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 84065.2(b)(1) Personnel Duties.

An exit interview was conducted, and appeal rights were reviewed with Elizabeth Rosas. Due to printer malfunction, a copy of this report, along with the LIC 811, and appeal rights will be emailed to the Facility Administrator. A signed copy of this report will be kept in the Facility file.
SUPERVISOR'S NAME: Ann ValenzuelaTELEPHONE: (951) -782-4968
LICENSING EVALUATOR NAME: Charmaine LinleyTELEPHONE: 951-202-1850
LICENSING EVALUATOR SIGNATURE:

DATE: 02/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 08-CR-20220822084410
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

FACILITY NAME: A.B. JESSIE POLINSKY CHILDREN'S CENTER
FACILITY NUMBER: 374603968
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/15/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/16/2023
Section Cited
CCR
84065.2(b)(1)
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Personnel Duties:
84065.2(b)(1) Child care staff shall perform the following duties…Supervision, protection and care of children individually and in groups at all times.
This requirement was not met as evidenced by:
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Per Administrator, an email will be sent to the Cottage Staff reminding staff that they must fully go into the bedrooms to check the clients on all shifts. LPA will receive a copy of the email by 5:00 pm on 02/16/23 Administrator will review the overnight checks form for the next 30 days.
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Based on confidential interviews and records reviewed, C1 snuck an unknown person into the cottage and this individual spent the night in the cottage. Records reviewed revealed this individual jumping the back fence onto the campus and leaving the campus the following morning. Confidential interviews revealed that C1 was observed in the bedroom with the individual and staff members did not fully check the bedroom, 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) -782-4968
LICENSING EVALUATOR NAME: Charmaine LinleyTELEPHONE: 951-202-1850
LICENSING EVALUATOR SIGNATURE:

DATE: 02/15/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3