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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603968
Report Date: 08/17/2023
Date Signed: 08/17/2023 01:52:05 PM

Document Has Been Signed on 08/17/2023 01:52 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
FACILITY NAME:A.B. JESSIE POLINSKY CHILDREN'S CENTERFACILITY NUMBER:
374603968
ADMINISTRATOR:ROSAS, ELIZABETHFACILITY TYPE:
721
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 204CENSUS: 30DATE:
08/17/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Elizabeth RosasTIME COMPLETED:
02:00 PM
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On 08/17/2023, at 1:00 pm, Licensing Program Analyst (LPA) Charmaine Linley and Licensing Program Manager (LPM) Ann Valenzuela conducted an unannounced inspection at the facility and met with Elizabeth Rosas, Norma Rincon, and Steven Wells. This inspection was a follow-up to the case management inspection completed on 01/04/2023. Refer to Confidential Names (LIC 811) dated 08/17/2023.

Community Care Licensing became aware of C1 being involved in a restraint in the gym on 12/03/2022. LPA conducted interviews with one client (C1), four staff (S1-3, S5), and was unable to interview two staff (S4, S6), despite multiple attempts to contact them. LPA reviewed the following documents: Staffing worksheet, Special Incident Report, C1’s Needs and Services Plan, C1’s IPP, and facility visitor log. LPA viewed the facility’s video recording of the gym dated 12/03/2022. The video recording showed C1 was sitting on the stage in the gym and S4 grabbed C1 by their arm and pulled the microphone out of their hands. C1 ran off the stage towards staff members and S6 restrained C1 on the gym floor. After a few minutes, S6 lets go of C1, C1 runs out of the gym, and drops to the ground outside of the gym door. S6 grabs C1 by the leg and drags them back into the gym. S4 and S5 are present while S6 grabs both of C1’s legs. C1 struggles and then S6 lets go of C1’s legs.

During the incident, the facility did not operate in accordance with the specified Plan of Operation – Emergency Intervention Plan. The facility’s plan of operation indicates Pro Act would be used in times when emergency intervention is needed. It is determined S6 did not follow the Pro Act principles by using S6's body to physically restrict C1’s movement. Staff present did not follow the facility’s plan of operation to use crisis intervention prior to physical interventions with children.

The video also shows a violation of personal rights where a client in care was dragged by two staff members. The video recording depicts S4 grabbing C1 by their arm and pulling them. The video evidence also shows
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SUPERVISORS NAME: Ann Valenzuela
LICENSING EVALUATOR NAME: Charmaine Linley
LICENSING EVALUATOR SIGNATURE: DATE: 08/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/17/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 08/17/2023
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S6 grabbing C1’s leg and dragging C1 by their leg. Confidential interviews indicated C1 was dragged by Staff. Based on observation of the video evidence, confidential interviews, and record review, the facility is being cited for a Type A violation of California Code of Regulations, Title 22 Division Six, regulation 80022(k): Plan of Operation – the facility shall operate in accordance with the terms specified in the plan of operation. Confidential interviews with staff and a client indicate the facility did not adhere to the plan of operations regarding emergency intervention and restraints. The video evidence supports this finding. Facility is also cited for a Type A violation of California Code of Regulations, Title 22 Division Six, regulation 84072(d): Personal Rights. 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, including the right to live in a safe, healthy, and comfortable home where they are treated with respect. The evidence shows the facility did not ensure personal rights were safeguarded when staff was able to roughly handle the client. The confidential interviews indicate the staff dragged the client. The video depicts two different staff grabbing the client and dragging the client. Both incidences pose an immediate health, safety, or personal rights risk to clients in care.

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.
SUPERVISORS NAME: Ann Valenzuela
LICENSING EVALUATOR NAME: Charmaine Linley
LICENSING EVALUATOR SIGNATURE:

DATE: 08/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/17/2023
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Document Has Been Signed on 08/17/2023 01:52 PM - It Cannot Be Edited


Created By: Charmaine Linley On 08/16/2023 at 09:30 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
,
, CA

FACILITY NAME: A.B. JESSIE POLINSKY CHILDREN'S CENTER
FACILITY NUMBER: 374603968

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/17/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/18/2023
Section Cited
CCR
80022(k):

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80022(k): Plan of Operation:
The facility shall operate in accordance with the terms specified in the plan of operation.

This requirement was not met as evidenced by:
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Per Administrator, S4 and S6 have been terminated from working at the facility. The facility has re-trained all staff to no longer use the prone or supine restraint and to utilize the enhanced Pro-Act principles as of 03/01/2023. Training list was provided.
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Based on confidential interviews and the video in the gym the facility did not adhere to the plan of operations as S6 used their body to restrict C1's movement which poses an immediate health, safety, and personal rights risk to clients in care.
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Type A
08/18/2023
Section Cited
CCR84072(d)

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84072(d): Personal Rights:
The licensee shall ensure 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, including the right to live in a safe, healthy, and
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Per Administrator, the facility has re-trained all staff to use the enhanced Pro-Act principles, which includes Response Framework and Crisis Communication. Training was completed 3/01/23. Annual training will be conducted and includes a pre and post test. Training list was provided.
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comfortable home where they are treated with respect.
This requirement was not met as evidenced by: S4 grabbing and pulling C1 and S6 grabbing and dragging C1, which poses 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 Valenzuela
LICENSING EVALUATOR NAME:Charmaine Linley
LICENSING EVALUATOR SIGNATURE:
DATE: 08/17/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/17/2023


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