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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374604207
Report Date: 12/18/2023
Date Signed: 12/18/2023 01:19:29 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
12/18/2023 and conducted by Evaluator Dawn Segura
COMPLAINT CONTROL NUMBER: 08-AS-20231218085815
FACILITY NAME:LIBERTY HARMONYFACILITY NUMBER:
374604207
ADMINISTRATOR:MANIPON, CHERIFERFACILITY TYPE:
737
ADDRESS:2915 DUCK POND LANETELEPHONE:
(760) 975-7176
CITY:RAMONASTATE: CAZIP CODE:
92065
CAPACITY:4CENSUS: 4DATE:
12/18/2023
UNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Cruz Mora, Assistant Program DirectorTIME COMPLETED:
01:35 PM
ALLEGATION(S):
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Licensee did not meet staff-client ratio for clients in care.

Licensee did not fulfill client consultation requirements.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Dawn Segura conducted a visit to commence a complaint investigation into the above identified allegations. LPA was granted entry into the facility by Destiny Westney, Lead BSP, and met with Cruz Mora, Assistant Program Director, who arrived a short time later and to whom LPA disclosed the purpose of the visit.

Community Care Licensing (CCL) has investigated the above-listed complaint allegations. The investigation consisted of a review of outside source records and interview of facility staff.

It was alleged that the licensee did not meet staff-client ratio for clients in care. It was reported that, based upon the needs of the clients in care, during the week of 8/20/2023 through 8/26/2023, the licensee was required to have a minimum of seven staff working on the PM shift. Interview conducted and a review of outside source records reflected that on 8/20/2023, from 8:00 PM to 10:00 PM, there were eight staff scheduled to work; however, only six staff were working in the facility due to two staff calling out sick. During
Substantiated
Estimated Days of Completion: 0
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dawn Segura
LICENSING EVALUATOR SIGNATURE:

DATE: 12/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/18/2023
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-20231218085815
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: 12/18/2023
NARRATIVE
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that span of two hours, the licensee did not have the minimum required number of staff providing client care.

It was also alleged that the licensee did not fulfill client consultation requirements. It was reported that each month, the licensee is required to ensure that each client is provided a minimum number of therapy hours. It has previously been disclosed to Community Care Licensing that the minimum number of hours each client is required to receive is agreed upon by the licensee. A review of records and interview conducted yielded that in the month of July 2023, Clients 1 (C1), 2 (C2), 3 (C3), and 4 (C4) [LIC 811 Confidential Names List was provided to identify the clients] did not receive the minimum number of mental health consultation hours agreed upon by the licensee.

Based upon the foregoing, the allegations are substantiated. This finding means that the preponderance of the evidence standard has been met and the allegations are valid. Deficiencies are cited per California Code of Regulations, Title 22, and are noted on the attached LIC9099-D. A civil penalty in the amount of $250 is being assessed, on an LIC 421FC, in response to the licensee not meeting the staff-client ratio, as the deficiency is a repeat violation within a 12-month period of time.

An exit interview was conducted with Cruz Mora, and copies of this report, the LIC 811, LIC 421FC, and Licensee/Appeal Rights (LIC9058) were provided at the conclusion of the visit. Cruz Mora’s signature on this report acknowledges receipt of copies of the reports and the rights.
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dawn Segura
LICENSING EVALUATOR SIGNATURE:

DATE: 12/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/18/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3
Control Number 08-AS-20231218085815
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/18/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/08/2024
Section Cited
CCR
80065(a)
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Personnel Requirements. Facility personnel shall be competent to provide the services necessary to meet individual client needs and shall, at all times, be employed in numbers necessary to meet such needs.
This requirement was not met as evidenced by:
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LPA Segura was informed that licensee has hired additional staff and increased the number of PRN staff available to fill when regularly scheduled staff call out. LPA was also informed that licensee has been scheduling one additional staff for the AM and PM shift to avoid staffing shortage
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Based on interview and review of records, licensee did not have personnel sufficient in numbers to meet the needs of 4 of 4 clients in care. This posed potential safety and personal rights violations to persons in care.
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on a shift.
Type B
01/08/2024
Section Cited
CCR
80022(k)
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Plan of Operation. The facility shall operate in accordance with the terms specified in the Plan of Operation and may be cited for not doing so.
This requirement was not met as evidenced by:
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LPA Segura was advised that an additional Mental Health Clinician has been hired, so whenever one clinician is off or not available, another clinician will be available to provide the required number of consultation hours.
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Based on record review, licensee did not operate in accordance with the facility’s Program Design relative to 4 of 4 clients in care. This posed potential health and personal rights violations to persons in care.
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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: Dawn Segura
LICENSING EVALUATOR SIGNATURE:

DATE: 12/18/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/18/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3