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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374604122
Report Date: 02/28/2024
Date Signed: 02/28/2024 04:49:03 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
07/14/2021 and conducted by Evaluator Liliana Silveira
PUBLIC
COMPLAINT CONTROL NUMBER: 08-AS-20210714145845
FACILITY NAME:MERAKEY COLTRANEFACILITY NUMBER:
374604122
ADMINISTRATOR:ROQUEMORE, CARLYFACILITY TYPE:
737
ADDRESS:1927 COLTRANE PLTELEPHONE:
(442) 286-7428
CITY:ESCONDIDOSTATE: CAZIP CODE:
92027
CAPACITY:4CENSUS: 4DATE:
02/28/2024
UNANNOUNCEDTIME BEGAN:
03:55 PM
MET WITH:Administrator in Training Paul WheelerTIME COMPLETED:
04:30 PM
ALLEGATION(S):
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Lack of supervision resulting in sexual abuse.
Facility did not meet client’s care needs.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Liliana Silveira conducted an unannounced complaint investigation visit. LPA Silveira introduced themselves, met with Administrator in Training Paul Wheeler and disclosed the purpose of the visit. The purpose of the visit was to deliver complaint findings for the above-mentioned allegations.

The Department’s investigation consisted of interviews with staff, clients and outside sources. The investigation also included a facility records review.

It was alleged that lack of supervision resulted in the sexual abuse of Client #1 (C1) by Client #2 (C2). It was also alleged that the facility did not meet C1’s care needs.

A review of facility records revealed that based on a Functional Behavorial Assessment dated 10/26/2020, C1 was diagnosed with autism spectrum disorder, obsessive-compulsive disorder, unspecified psychotic disorder and mild intellectual disabilities. C1’s Regional Center Individual Program Plan (IPP), with start date of 11/04/2020, indicated that for living arrangements, C1 required one-on-one staff support. The IPP also indicated that the facility was responsible for ensuring an adequate level of staff ratio and supervision.

The review of facility records also revealed that based on a Functional Behavioral Assessment dated 08/27/2019, C2 was diagnosed with an intellectual disability and a mild unspecified impulse control disorder. A review of C2’s Regional Center Individual Program Plan (IPP), dated 08/28/2019, revealed that C2 required general supervision while in the facility. [CONTINUED ON LIC 9099-C]
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Liliana Silveira
LICENSING EVALUATOR SIGNATURE:

DATE: 02/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/28/2024
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-AS-20210714145845
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: MERAKEY COLTRANE
FACILITY NUMBER: 374604122
VISIT DATE: 02/28/2024
NARRATIVE
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[CONTINUED FROM 9099] The IPP also indicated that C2 engages in maladaptive behaviors, and it was important for staff to be aware of these maladaptive behaviors while supervising C2.

An interview by the Department with an outside source on 07/20/2021 revealed that C1 communicated to another outside source that C2 had prompted C1 to engage in a sexual act on 06/15/2021. An interview by the Department with C2 on 10/27/2021 also revealed that C2 admitted to prompting C1 to engage in a sexual act. During the interview, C2 also stated that no staff where present when the incident occurred and C2 did not know where staff were. In an interview with the facility Program Administrator (PA), it was disclosed that on 06/16/21 C2 told the PA, the Director and staff that they had touched C1 and promised not to ever do it again.

An interview by the facility Director on 10/27/21 revealed that Staff #1 (S1), assigned to C1, should have been right next to C1. Staff #2 (S2), assigned to C2, also should have been in line-of-sight of C2. An interview with (S1) by the Department on 08/18/2021 revealed that S1 was C1’s Direct Support Professional (DSP). S1 stated that on the date of the incident, 06/15/21, C1 was left in their bedroom and S1 went to the kitchen to work on tasks. S1 stated that they found out the next day about the incident. S1 admitted that they should have been more vigilant with C1. An interview by the Department with the Director on 10/27/21 also revealed that facility video camera footage had been reviewed for the date of the incident, 06/15/2021, and showed C1 coming out of their bedroom and C2 coming out of the bathroom at the same time. The video footage also showed S1 and S2 being 100 feet away from the clients in the kitchen.

Based on interviews and records review, the above-listed allegations were determined to be substantiated. A substantiated finding means the allegations are valid because the preponderance of the evidence standard has been met. Pursuant to the California Code of Regulations, Title 22, Division 6, the deficiencies are cited on the attached LIC 9099-D.

An exit interview was conducted and a copy of this report along with the Licensee Rights (LIC 9058 01/16) were provided to Paul Wheeler, whose signature below confirms receipt of these rights.
SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Liliana Silveira
LICENSING EVALUATOR SIGNATURE:

DATE: 02/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/28/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 08-AS-20210714145845
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: MERAKEY COLTRANE
FACILITY NUMBER: 374604122
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/28/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/29/2024
Section Cited
CCR
80078(a)
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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 was not met as evidenced by: based on interviews and records review, facility staff failed to...
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Facility management implemented new safety measures and an immediate behavioral modification plan for both clients when the incident occurred. Administrator will submit plan that was implemented and corrective action report to CCLD by 02/29/24.
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ensure that Client #1 (C1) was provided required one-on-one staff to client supervision, resulting in C1 being sexually abused by another client. This posed an immediate health and safety risk to C1.
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Type B
03/28/2024
Section Cited
CCR
85078(a)(1)
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85078 Responsibility for Providing Care and Supervision: (a) (1) The licensee shall provide those services identified in the client's needs and services plan as necessary to meet the client's needs. This requirement was not met as evidenced by: based on interviews...
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Facility management reinforced that staff must adhere to Care Plan. Client's plans were updated to reflect need to increased supervision. Administrator will submit proof of training and updated plan to CCLD by 03/28/24.
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and records review, facility staff failed to follow Client #1(C1's) Needs & Services Plan, which posed a potential health risk to C1.
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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.
SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Liliana Silveira
LICENSING EVALUATOR SIGNATURE:

DATE: 02/28/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/28/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3