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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374604208
Report Date: 03/09/2022
Date Signed: 03/09/2022 04:47:22 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
07/27/2021 and conducted by Evaluator Rebecca A Ruiz
COMPLAINT CONTROL NUMBER: 08-AS-20210727103703
FACILITY NAME:LIBERTY TRANQUILITYFACILITY NUMBER:
374604208
ADMINISTRATOR:BLACKSHEAR, SHAWNFACILITY TYPE:
737
ADDRESS:1404 ASH STREETTELEPHONE:
(760) 654-6277
CITY:RAMONASTATE: CAZIP CODE:
92065
CAPACITY:4CENSUS: 3DATE:
03/09/2022
UNANNOUNCEDTIME BEGAN:
11:50 AM
MET WITH:Morgan DavisTIME COMPLETED:
12:30 PM
ALLEGATION(S):
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Facility failed to provide running hot water
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Rebecca Ruiz and Licensing Program Manager (LPM) Lizzette Tellez conducted an unannounced complaint visit to deliver findings regarding the above-mentioned allegation. LPA and LPM were greeted by, identified themselves to, and explained the purpose of the visit with Quality Assurance Manager Morgan Davis.

The Department’s investigation consisted of interviews with staff, clients, and outside sources, review of records, and a tour of the facility. It was alleged that the facility did not provide running hot water to clients in care. Investigative interviews and record review revealed that the facility did not have hot water between 7/24/2021 to 7/28/2021. Facility staff notified the property manager of the lack of hot water on 7/24/2021. Record review revealed the property manager did not consider the lack of hot water to be an emergency and did not require immediate repairs. The licensee contracted a plumbing company who attempted to repair the hot water issue on 7/24/2021 and 7/26/2021 but were unable to restore the hot water on either day.
Continued on LIC9099-C page.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Alexandre Vo
LICENSING EVALUATOR NAME: Rebecca A Ruiz
LICENSING EVALUATOR SIGNATURE:

DATE: 03/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/09/2022
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-20210727103703
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 TRANQUILITY
FACILITY NUMBER: 374604208
VISIT DATE: 03/09/2022
NARRATIVE
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On 7/25/2021, the hot water was measured at 84.4 degrees Fahrenheit by facility staff. Facility staff also informed the Department of the lack of hot water on 7/26/2021. The plumbing company contracted by the Licensee was able to restore the hot water for client use on 7/28/2021. During the initial complaint visit on 8/4/2021, the hot water was measured within regulation guidelines.

Based on the evidence obtained during the investigation, the Department has found that the facility did not provide hot running water to clients in care. Therefore, the allegation is deemed substantiated, which means the preponderance of the evidence standard has been met and the allegation is valid. A Technical Violation was issued and noted on the attached LIC9102 page.

An exit interview was conducted with Quality Assurance Manager Morgan Davis. A copy of this report, the LIC9102, and the Licensee Rights (LIC9058 01/16) were provided to Morgan Davis via hardcopy.

This is an amended version of the report created on March 9, 2022.
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Rebecca A Ruiz
LICENSING EVALUATOR SIGNATURE:

DATE: 03/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/09/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 08-AS-20210727103703
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 TRANQUILITY
FACILITY NUMBER: 374604208
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/09/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type B
03/14/2022
Section Cited
CCR
80088(e)(1)
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80088 Furniture, Fixtures, Equipment, and Supplies (e) (1) Hot water temperature controls shall be maintained to … not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C). This requirement has not been met as evidenced by:
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Licensee's contracted plumber restored hot water 7/28/2021. LPA observed hot water was restored during a visit on 8/4/2021. Additionally, Licensee has implimented a hot water outage drill to be conducted on a quarterly basis. Licensee will provide a copy of the policy and schedule to CCLD by POC date.
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Based on interviews and record review, the Licensee did not to provide hot water to two of two clients between 7/24/2021 and 7/28/2021 which posed a potential Health risk to clients 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: Alexandre Vo
LICENSING EVALUATOR NAME: Rebecca A Ruiz
LICENSING EVALUATOR SIGNATURE:

DATE: 03/09/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/09/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3