374603968-5-15-2023-08-CR-AVAA-CS2PJW-20230521112213

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374603968
Report Date: 05/15/2023
Date Signed: 05/15/2023 04:29:06 PM

Unsubstantiated

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
02/17/2023 and conducted by Evaluator Charmaine Linley

PUBLIC

COMPLAINT CONTROL NUMBER: 08-CR-20230217152548

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: 23	DATE:	05/15/2023
		UNANNOUNCED	TIME BEGAN:	02:45 PM
MET WITH:	Alicia Rogers		TIME COMPLETED:	03:45 PM

ALLEGATION(S):

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Staff is physically assaulting minor while in care.

INVESTIGATION FINDINGS:

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On May 15, 2023, at 2:45, Licensing Program Analyst (LPA) Charmaine Linley arrived unannounced at the facility and met with Alicia Rogers, Protective Services Program Manager to discuss the investigative finding for the allegation noted above. LPA conducted an inspection of the facility on 02//24/2023 at 3:00 pm and no deficiencies were observed. LPA Linley interviewed three clients (C1-3), and ten staff (S1-10), and attempted to interview one Protective Services Worker (PSW), however, was unable to contact them despite multiple attempts. LPA reviewed the following documents during the investigation: Nursing Notes, Special Incident Report, S1 Employee Evaluation, Staffing Worksheets, and Child History Report.

On 02/17/2023, Community Care Licensing (CCL) received an allegation that staff is physically assaulting C1 while in care. It was reported that when C1 tried to AWOL, S5 blocked C1 from leaving, C1 tried to crawl between S5's legs, and S5 pinned C1’s head against the wall. Confidential interviews revealed conflicting statements, some interviews reported C1 did not crawl through the legs of S5 and S5 did not
***CONTINUED ON NEXT PAGE

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Ann Valenzuela
LICENSING EVALUATOR NAME: Charmaine Linley
LICENSING EVALUATOR SIGNATURE:	DATE: 05/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2023

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-20230217152548

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: 05/15/2023

NARRATIVE

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pin C1 against a wall. Conflicting interviews reported that another staff pushed C1 with their legs outside C1’s bedroom door.

Based on confidential interviews and records reviewed that staff is physically assaulting C1 while in care, which may or may not have occurred, however, it is not supported or proven by the evidence. Therefore, the allegation is unsubstantiated at this time.

An exit interview was conducted, appeal rights explained, and a copy of this report was reviewed with Alicia Rogers. Due to printer malfunction, a copy of this report, LIC 811, and appeal right will be emailed to the Administrator. A copy of this report will be placed in the facility file.

SUPERVISORS NAME: Ann Valenzuela
LICENSING EVALUATOR NAME: Charmaine Linley
LICENSING EVALUATOR SIGNATURE:	DATE: 05/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2023

LIC9099 (FAS) - (06/04)

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