374604207-11-21-2023-08-AS-SJAB-CY4243-20231130160317

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374604207
Report Date: 11/21/2023
Date Signed: 11/21/2023 12:54:33 PM

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
11/15/2023 and conducted by Evaluator Dawn Segura

COMPLAINT CONTROL NUMBER: 08-AS-20231115114706

FACILITY NAME:	LIBERTY HARMONY		FACILITY NUMBER:	374604207
ADMINISTRATOR:	MANIPON, CHERIFER		FACILITY TYPE:	737
ADDRESS:	2915 DUCK POND LANE		TELEPHONE:	(760) 975-7176
CITY:	RAMONA	STATE: CA	ZIP CODE:	92065
CAPACITY:	4	CENSUS: 4	DATE:	11/21/2023
		UNANNOUNCED	TIME BEGAN:	11:45 AM
MET WITH:	Dietrich Kuhns, BSP		TIME COMPLETED:	01:05 PM

ALLEGATION(S):

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Delayed egress gate is in disrepair.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Dawn Segura conducted an unannounced visit to initiate an investigation into the above-listed complaint allegation. LPA was granted entry into the facility and met with Dietrich Kuhns, Acting Lead Behavioral Support Professional (BSP). Morgan Davis, Quality Assurance Manager, was contacted via telephone, to whom LPA disclosed the purpose of the visit.

It was reported that during a visit to the facility conducted on November 9, 2023, the delayed egress gate was not functioning.

Community Care Licensing (CCL) has investigated the above-listed allegation. The investigation consisted of a tour of the facility and interview of facility staff. Information obtained during the investigation revealed that the delayed egress gate has intermittently malfunctioned when the magnets located at the top of the gate have not securely connected. The investigation also revealed that facility staff have previously reached out to the home’s property managers to repair the gate; however, during visits by the management company, the

Unsubstantiated

Estimated Days of Completion: 0

SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dawn Segura
LICENSING EVALUATOR SIGNATURE:	DATE: 11/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2023

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-20231115114706

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: 11/21/2023

NARRATIVE

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gate has functioned properly, and the problem has not been able to be replicated. Interview further revealed that facility staff reached out to the property managers on November 9, 2023 and November 20, 2023 to have the issue addressed. As of this time, the property managers have not visited the property to address the issue. The investigation also yielded that facility staff have increased client supervision and are testing the delayed egress gate each day on the AM and PM shifts. Additionally, facility staff are in the process of developing an action plan to address the intermittent malfunctioning of the gate on a long term basis.

Upon arrival, LPA attempted to open the delayed egress gate located at the front of the house. The gate was locked at the time of the attempt, and LPA was not able to open it from the outside. Considering all of the foregoing, the allegation is unsubstantiated. This finding means that there is not a preponderance of the evidence to prove that the alleged violation occurred.

An exit interview was conducted with Dietrich Kuhns, and a copy of this report and Licensee/Appeal Rights (LIC 9058) were provided to the BSP at the conclusion of the visit. His signature below serves as acknowledgment of receipt of copies of the report and rights.

SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dawn Segura
LICENSING EVALUATOR SIGNATURE:	DATE: 11/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2023

LIC9099 (FAS) - (06/04)

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