374604208-1-13-2023-08-AS-LTEZ-CNMAX8-20230131233619

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374604208
Report Date: 01/13/2023
Date Signed: 01/13/2023 03:05:30 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
11/10/2022 and conducted by Evaluator Dawn Segura

COMPLAINT CONTROL NUMBER: 08-AS-20221110133924

FACILITY NAME:	LIBERTY TRANQUILITY		FACILITY NUMBER:	374604208
ADMINISTRATOR:	SMITH, DAVID		FACILITY TYPE:	737
ADDRESS:	1404 ASH STREET		TELEPHONE:	(760) 654-6277
CITY:	RAMONA	STATE: CA	ZIP CODE:	92065
CAPACITY:	4	CENSUS: 4	DATE:	01/13/2023
		UNANNOUNCED	TIME BEGAN:	02:15 PM
MET WITH:	David Smith, Program Director		TIME COMPLETED:	03:10 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 conclude a complaint investigation. LPA was granted entry into the facility and met with David Smith, Program Director, to whom she disclosed the purpose of the visit.

Community Care Licensing (CCL) has investigated the above listed complaint allegations. The investigation consisted of a review of facility and outside source records and interviews with 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 7/24/2022 through 7/30/2022, the licensee was required to have a minimum of five staff working on each of the AM and PM shifts and a minimum of four staff working on the nocturnal shift. Interviews conducted and a review of facility and outside source records reflected that on 7/30/2022, from approximately 5:00 PM to 10:00 PM, there were four staff working in the facility due to a staff’s departure and no staff present to fill in the spot. During that span of five hours, the

Substantiated

Estimated Days of Completion: 0

SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dawn Segura
LICENSING EVALUATOR SIGNATURE:	DATE: 01/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/13/2023

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-20221110133924

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: 01/13/2023

NARRATIVE

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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. Information was obtained during the investigation to determine that the minimum number of hours each client is required to receive is agreed upon by the licensee. A review of facility and outside source records reflected that in the month of September 2022, Clients 1 (C1), 2 (C2), and 3 (C3) [LIC 811 Confidential Names List was provided to identify the clients] did not receive the minimum number of therapy hours required, and in July 2022, C2 and C3 did not receive the minimum agreed upon number of required therapy hours.

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.

An exit interview was conducted with David Smith, Program Director, and copies of this report and Licensee/Appeal Rights (LIC9058) were provided to the Program Director at the conclusion of the visit. David Smith’s signature on this report acknowledges receipt of the report and the rights.

**This is an amended version of the original report created on 01/13/2023.**

SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dawn Segura
LICENSING EVALUATOR SIGNATURE:	DATE: 01/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/13/2023

LIC9099 (FAS) - (06/04)

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Control Number 08-AS-20221110133924

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: 01/13/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 01/31/2023 Section Cited CCR 80065(a)	1 2 3 4 5 6 7	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:	1 2 3 4 5 6 7	Program Director offered to provide a completed LIC 500 and written staffing contingency plan for staff call-outs and shortages to Community Care Licensing by the POC due date.
	8 9 10 11 12 13 14	Based on interview and review of records, licensee did not have personnel sufficient in numbers to meet the needs of clients in care. This posed potential safety and personal rights violations to 3 of 3 clients in care.	8 9 10 11 12 13 14
Type B 01/31/2023 Section Cited CCR 80022(k)	1 2 3 4 5 6 7	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:	1 2 3 4 5 6 7	Program Director stated that a meeting has been conducted with the consulting agency to establish an ongoing calendaring system to ensure that the required number of hours are met for each client each month. Program Director offered to consult with the Executive Director to establish a means of reconciling
	8 9 10 11 12 13 14	Based on record review, licensee did not operate in accordance with the facility’s Program Design. This posed a potential personal rights violation to C1, C2, and C3, three of four clients in care.	8 9 10 11 12 13 14	billing by Liberty Residential with the outside consulting agency to ensure that all are in alignment. A report of the results of the meeting and plan of action for reconciliation will be provided to Community Care Licensing by the POC due date.

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: 01/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/13/2023

LIC9099 (FAS) - (06/04)

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