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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374604148
Report Date: 01/09/2024
Date Signed: 01/09/2024 03:28:04 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, 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
09/16/2020 and conducted by Evaluator Rebecca A Ruiz
COMPLAINT CONTROL NUMBER: 08-AS-20200916164625
FACILITY NAME:ABIGAIL'S HOMES IIFACILITY NUMBER:
374604148
ADMINISTRATOR:GONZALEZ, BRENDA ABIGAILFACILITY TYPE:
735
ADDRESS:8738 VALENCIA STTELEPHONE:
(619) 315-7407
CITY:SPRING VALLEYSTATE: CAZIP CODE:
91977
CAPACITY:4CENSUS: 3DATE:
01/09/2024
UNANNOUNCEDTIME BEGAN:
02:20 PM
MET WITH:Caregiver Dario GonzalezTIME COMPLETED:
03:15 PM
ALLEGATION(S):
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Lack of supervision resulting in client sustained multiple injuries while in care
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Rebecca Ruiz conducted an unannounced complaint visit to deliver findings regarding the above-mentioned allegation. LPA identified herself to, was greeted by, and explained the purpose of the visit to Caregiver Dario Gonzalez. LPA spoke to Administrator Brenda Gonzalez via phone.

The Department’s investigation consisted of interviews with clients, staff, and outside sources, records review, and a virtual tour of the facility. It was alleged that lack of supervision resulted in Client 1 (C1) sustaining multiple injuries. [LPA provided Dario with an LIC811 Confidential Names list to identify C1] Review of C1’s pre-placement assessment and updated physician’s report revealed that C1 was ambulatory, had a diagnosis of epilepsy, was able to perform activities of daily living independently, required the use of grab bars in the bathroom, and did not require assistance with bathing or showering. Interviews with staff, clients, and outside sources revealed that C1 was able to verbalize their needs, pain, or sickness.

Continued on LIC9099-C page...
Substantiated
Estimated Days of Completion: 0
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Rebecca A Ruiz
LICENSING EVALUATOR SIGNATURE:

DATE: 01/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2024
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 4
Control Number 08-AS-20200916164625
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: ABIGAIL'S HOMES II
FACILITY NUMBER: 374604148
VISIT DATE: 01/09/2024
NARRATIVE
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Review of C1’s seizure record revealed that C1 had 38 seizures between July and August 2020 and C1 had multiple seizures on the same day, but those records did not provide any information regarding any injuries that C1 may have sustained as a result of the seizure.

Interviews and review of medical records for C1 revealed that in September 2020, C1 was seen at the hospital for an evaluation after a seizure that occurred in the bathroom. Evaluation of C1 by hospital staff revealed that C1 sustained a face laceration and that C1 also had bruising to the inner thighs. Interviews with C1 and facility staff did not reveal any indication of the cause of the bruising on C1’s thighs. Interviews with staff revealed that staff did not conduct thorough body checks of clients, including C1, during showers or during assessments for injuries. C1 denied any inappropriate physical or verbal interactions or rough treatment by facility staff. Facility staff denied any inappropriate physical or verbal interactions or rough treatment of clients, including C1.

C1 stated that both male and female staff assisted C1 with bathing, however, interviews with staff revealed that only female staff assisted female clients with showering. Interviews with staff revealed that staff would assist C1 to set up prior to a shower and would leave C1 alone in the bathroom to shower. Assessment and care records and interviews with staff and clients revealed that C1 showered independently while using a shower chair and staff were instructed to check on C1 periodically by asking C1 if they needed any assistance through the door. Interviews with staff and clients and review of incident reports submitted to the Department in 2020 revealed that C1’s seizures would occur without warning and that C1 had fallen in the bathroom during a seizure in the past. Interviews with staff revealed that C1 would sustain injuries due to falling or hitting objects during seizures and in the past, hospital staff had voiced concerns to facility staff regarding bruising and marks that C1 sustained. Interviews revealed that staff were not always able to prevent C1 from falling during a seizure. When C1 had a seizure while in the bathroom, C1 was able to call for staff through the door and request assistance. Interviews with staff revealed that C1 was considered a fall risk and in response, the facility staff had installed floor padding to C1’s room, installed grab bars in facility bathrooms, and C1 used a padded helmet to prevent head injuries.

Continued on LIC9099-C page...
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Rebecca A Ruiz
LICENSING EVALUATOR SIGNATURE:

DATE: 01/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 08-AS-20200916164625
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: ABIGAIL'S HOMES II
FACILITY NUMBER: 374604148
VISIT DATE: 01/09/2024
NARRATIVE
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Review of C1’s assessment records and interviews with facility staff and management revealed that C1’s records had not been updated to show that C1 was a fall risk, but facility staff had been verbally informed that C1 was a fall risk by the Administrator. Despite facility staff knowledge that C1 was a fall risk and multiple instances where C1 had a seizure resulting in injuries including while in the bathroom, staff were not instructed to remain in the bathroom with C1 to assist in the event of a seizure. Interviews with staff revealed concerns that C1’s care needs had increased beyond the ability of staff to provide proper assistance.

The Department has investigated the above-mentioned allegation and based on interviews and records review, the preponderance of the evidence has been met, therefore, this allegation is deemed substantiated. The following deficiency is cited per CA Code of Regulations Title 22 and noted on the attached LIC9099-D page.

An exit interview was conducted with Administrator Brenda Gonzalez via phone and Caregiver Dario Gonzalez, whose signature below confirms receipt of a copy of this report and the Licensee Appeal Rights (LIC9058 01/16).
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Rebecca A Ruiz
LICENSING EVALUATOR SIGNATURE:

DATE: 01/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 4
Control Number 08-AS-20200916164625
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: ABIGAIL'S HOMES II
FACILITY NUMBER: 374604148
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/09/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/10/2024
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 has not been met as evidenced by:
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Administrator stated staff will provide standby assistance for C1 while showering and Administrator will contact Regional Center for an updated assessment to add standby supervision while showering to C1's care plan.
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Based on interviews and records review, the licensee did not ensure that 1 of 4 clients (C1) was provided supervision necessary to meet C1’s needs while showering due to C1’s medical condition and fall risk determination. This poses an immediate health and safety risk to C1.
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 Administrator will provide by staff sign sheet POC due date of 1/10/2024.
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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: Lizzette Tellez
LICENSING EVALUATOR NAME: Rebecca A Ruiz
LICENSING EVALUATOR SIGNATURE:

DATE: 01/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 4