374603968-2-6-2023-08-CR-AVAA-CNWS97-20230210124016

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374603968
Report Date: 02/06/2023
Date Signed: 02/06/2023 02:59:28 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA

This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/01/2022 and conducted by Evaluator Eduardo Barragan

PUBLIC

COMPLAINT CONTROL NUMBER: 08-CR-20220601105654

FACILITY NAME:	A.B. JESSIE POLINSKY CHILDREN'S CENTER		FACILITY NUMBER:	374603968
ADMINISTRATOR:	ROSAS, ELIZABETH		FACILITY TYPE:	721
ADDRESS:			TELEPHONE:
CITY:		STATE:	ZIP CODE:
CAPACITY:	204	CENSUS: 36	DATE:	02/06/2023
		UNANNOUNCED	TIME BEGAN:	01:55 PM
MET WITH:	Elizabeth Rosas, Protective Services Program Manager.		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Staff do not prevent child from engaging in self-harming behavior while in care

INVESTIGATION FINDINGS:

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On February 6, 2023 at 1:55 PM, Licensing Program Analyst (LPA) Eduardo Barragan conducted a complaint inspection at A.B. Jessie Polinsky and met with Elizabeth Rosas, Protective Services Program Manager. The purpose of the inspection was to deliver the findings for the above complaint allegation. LPA Gloria Meza-Gonzalez inspected the facility on June 09, 2022 and noted no deficiencies.

LPA interviewed four of four clients (C1-C4) and interviewed four of four staff (S1-S4). LPA Barragan attempted to interview six staff (S1-S6) however, after numerous attempts LPA Barragan was unable to reach the staff.

Substantiated

Estimated Days of Completion: 0

SUPERVISOR'S NAME: Ann Valenzuela	TELEPHONE: (951) -782-4968
LICENSING EVALUATOR NAME: Eduardo Barragan	TELEPHONE: 714-380-0446
LICENSING EVALUATOR SIGNATURE:	DATE: 02/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/06/2023

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-CR-20220601105654

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA

FACILITY NAME: A.B. JESSIE POLINSKY CHILDREN'S CENTER	FACILITY NUMBER: 374603968
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/06/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 02/07/2023 Section Cited ILS 8078(a)	1 2 3 4 5 6 7	80078 Responsibility for Providing Care and Supervision (a) The licensee shall provide care and supervision as necessary to meet the client's needs. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	The Licensee stated that will get back to LPA Barragan as to their plan of correction.
	8 9 10 11 12 13 14	Based on interviews and record review the License did not ensure that staff provided care and supervision necessary to meet the clients needs. Which poses an immediate health and safety risk to the 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.

SUPERVISOR'S NAME: Ann Valenzuela	TELEPHONE: (951) -782-4968
LICENSING EVALUATOR NAME: Eduardo Barragan	TELEPHONE: 714-380-0446
LICENSING EVALUATOR SIGNATURE:	DATE: 02/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/06/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 08-CR-20220601105654

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA

FACILITY NAME: A.B. JESSIE POLINSKY CHILDREN'S CENTER	FACILITY NUMBER: 374603968
	VISIT DATE: 02/06/2023

NARRATIVE

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The Department has investigated the complaint that was received on June 6, 2022, alleging that staff do not prevent C1 from engaging in self-harming behavior while in care. Interviews with staff and clients confirmed that staff was not preventing C1 from engaging in self-harm behaviors while in care, due to staff not properly supervising C1. There were numerous incident reports regarding C1 engaging in self-harming behaviors, yet no proactive actions were taken to prevent further harm to C1. While conducting interviews it revealed certain staff were not preventing C1 for self-harming themself even after C1 explicitly informed staff that they were going to engage in self-harm. Numerous interviews confirmed this information as well. There are corroborating statements regarding the allegations.

Based on LPA's observations, interviews conducted, and record reviews, the preponderance of evidence standard has been met, therefore, the above allegation is found to be SUBSTANTIATED. Interim Licensing Standards Section 80078(a) Responsibility for Providing Care and Supervision are being cited on the attached LIC 9099D.

An exit interview was conducted, and a copy of the report and appeal rights were provided to Elizabeth Rosas, Protective Services Program Manager.

SUPERVISOR'S NAME: Ann Valenzuela	TELEPHONE: (951) -782-4968
LICENSING EVALUATOR NAME: Eduardo Barragan	TELEPHONE: 714-380-0446
LICENSING EVALUATOR SIGNATURE:	DATE: 02/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/06/2023

LIC9099 (FAS) - (06/04)

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