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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374604207
Report Date: 09/21/2021
Date Signed: 09/21/2021 11:06:49 AM

Unsubstantiated


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
06/29/2021 and conducted by Evaluator Liliana Silveira
PUBLIC
COMPLAINT CONTROL NUMBER: 08-AS-20210629131649
FACILITY NAME:LIBERTY HARMONYFACILITY NUMBER:
374604207
ADMINISTRATOR:WEBB, IVYFACILITY TYPE:
737
ADDRESS:2915 DUCK POND LANETELEPHONE:
(760) 975-7176
CITY:RAMONASTATE: CAZIP CODE:
92065
CAPACITY:4CENSUS: 3DATE:
09/21/2021
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Morgan Davis, QA ManagerTIME COMPLETED:
11:15 AM
ALLEGATION(S):
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Staff are not following proper COVID-19 protocols.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Liliana Silveira conducted a complaint investigation visit to deliver findings for the above allegation. LPA Silveira met with QA Manager Morgan Davis and shared the findings.

The Department’s investigation consisted of interviews, outside source documents, a tour of the facility and facility records review. On 06/29/21, it was alleged that facility staff were not following proper COVID-19 protocols, more specifically, in reference to proper Personal Protective Equipment (PPE) disposal. During an interview, the Program Director Brittany Carter demonstrated knowledge of proper PPE disposal. During the tour, it was observed that trash cans were located throughout the facility, including in clients’ bedrooms. Large outdoor waste bins were also observed for proper storage of waste. Records such as staff logs and training material demonstrated that all facility staff are trained monthly by the facility nurse on proper donning and doffing of PPE, including the disposal of PPE in waste containers. LPA spoke with staff who demonstrated how they dispose of PPE. Outside source information also indicated that wind could have been a possible contributing factor in PPE having been blown into a nearby canyon.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Liliana Silveira
LICENSING EVALUATOR SIGNATURE:

DATE: 09/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2021
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 2
Control Number 08-AS-20210629131649
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: LIBERTY HARMONY
FACILITY NUMBER: 374604207
VISIT DATE: 09/21/2021
NARRATIVE
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Based on the evidence obtained from the complaint investigation, the allegation that staff are not following proper COVID-19 protocols is found to be UNSUBSTANTIATED, meaning that there is not a preponderance of evidence to find that allegation true.

An exit interview was conducted and a copy of this report and Licensee's Rights (9058 01/16) were provided to QA Manager Morgan Davis, whose signature on this form confirms receipt of these documents.
SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Liliana Silveira
LICENSING EVALUATOR SIGNATURE:

DATE: 09/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 2