374604078-3-23-2022-08-AS-SJAB-CCZKLD-20220330075943

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374604078
Report Date: 03/22/2022
Date Signed: 03/23/2022 09:28:34 AM

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
03/17/2020 and conducted by Evaluator Debbie Correia

COMPLAINT CONTROL NUMBER: 08-AS-20200317143554

FACILITY NAME:	MARYAM RCFE		FACILITY NUMBER:	374604078
ADMINISTRATOR:	DOST, LEEDA		FACILITY TYPE:	740
ADDRESS:	4930 MAIDEN LANE		TELEPHONE:	(858) 348-7247
CITY:	LA MESA	STATE: CA	ZIP CODE:	91942
CAPACITY:	6	CENSUS: 6	DATE:	03/22/2022
		UNANNOUNCED	TIME BEGAN:	04:00 PM
MET WITH:	Caregiver Maria Lerma		TIME COMPLETED:	04:35 PM

ALLEGATION(S):

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Physical abuse by staff towards resident.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Debbie Correia conducted an unannounced visit to deliver investigative findings on the above listed complaint allegation. LPA was met and granted entry into the facility by Caregiver Maria Lerma to whom was explained the purpose for the visit.

The Department’s investigation consisted of staff and outside source interviews . The investigation also included facility, client, and outside source records reviews, observations and interactions with clients in care, and a facility tour.

It was alleged that on March 17, 2020 Client1 (C1) (See Confidential Name List LIC 811) sustained bruising by a Staff (S1) member who grabbed C1 by the arm pulling them back into the facility from the facility balcony. An interview with facility staff revealed C1 was upset after an argument with another client and began hitting and scratching themselves out on the facility balcony. Facility staff redirected and coaxed C1 back into the facility. C1 continued to act out and make suicidal threats. Staff called 911 and C1 was transported to the hospital and placed on observation.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Simon Jacob	TELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Debbie Correia	TELEPHONE: (619) 407-0894
LICENSING EVALUATOR SIGNATURE:	DATE: 03/22/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2022

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-AS-20200317143554

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: MARYAM RCFE	FACILITY NUMBER: 374604078
	VISIT DATE: 03/22/2022

NARRATIVE

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A review of facility records review, as well as interviews with facility staff and outside sources revealed there was not a staff member (S1) working at the facility by the name identified as the alleged suspect. A review of outside source records revealed C1 had a chronic problem of fabricating stories, such as abuse by staff and/or clients, to deflect blame onto others, it was also noted in records that placement facilities should be aware of this behavior due to serious allegations C1 has made in the past, all determined to be unfounded or unsubstantiated. Records also revealed C1 displayed re-occurring self-harm behaviors and suicide threats. An interview with an outside source and facility staff corroborated C1’s tendency to fabricate stories and also corroborated C1 had several incidents of self-harm, including hitting and scratching themselves.

An interview with another outside revealed they have recently, since discharge of C1, conducted visits to the facility on a regular basis. The Interview revealed never witnessing any issues or signs of abuse by staff, the clients in care always appeared well cared for and happy. The interview also revealed the clients are outspoken and have good relationships with the Licensee and Caregiver Lerma, and felt if there were any issues clients would not have any hesitation with reporting them.

Due to lack of corroborating evidence, the findings regarding the above allegation was determined to be unsubstantiated. This finding means although the allegation may have happened or could be valid, there is not a preponderance of evidence to prove that the alleged violation occurred.

An exit interview was conducted with Caregiver Lerma and Licensee Dost, who joined during the exit interview via telephone. A copy of this report along with Licensee/Appeal Rights (LIC 9058 01/16) will be provided to Caregiver Lerma and Licensee Dost via email at the conclusion of the visit. An electronic email read receipt confirms the documents were received.

SUPERVISOR'S NAME: Simon Jacob	TELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Debbie Correia	TELEPHONE: (619) 407-0894
LICENSING EVALUATOR SIGNATURE:	DATE: 03/22/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2022

LIC9099 (FAS) - (06/04)

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