374604208-9-22-2023-08-AS-IESA-CW869L-20231001203655

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374604208
Report Date: 09/22/2023
Date Signed: 09/22/2023 02:21:45 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
06/03/2020 and conducted by Evaluator Dawn Segura

COMPLAINT CONTROL NUMBER: 08-AS-20200603112940

FACILITY NAME:	LIBERTY TRANQUILITY		FACILITY NUMBER:	374604208
ADMINISTRATOR:	BLACKSHEAR, SHAWN		FACILITY TYPE:	737
ADDRESS:	1404 ASH STREET		TELEPHONE:	(760) 654-6277
CITY:	RAMONA	STATE: CA	ZIP CODE:	92065
CAPACITY:	4	CENSUS: 4	DATE:	09/22/2023
		UNANNOUNCED	TIME BEGAN:	01:40 PM
MET WITH:	Morgan Davis, Director of Quality Assurance and Training		TIME COMPLETED:	02:10 PM

ALLEGATION(S):

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Neglect/Lack of Supervision resulted in client sustaining a head injury while in care.
Facility did not arrange necessary medical services for a client.
Facility staff neglected a client's care needs.
Facility staff punished a client by withholding food.
Facility staff did not meet a client’s incontinent care needs.
Facility staff mismanaged client's medications.
Facility did not reassess a client following a change in condition.
Facility did not follow reporting requirements.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Dawn Segura conducted an unannounced visit to deliver investigative findings. LPA was granted entry into the facility and met with Morgan Davis, Director of Quality Assurance and Training, to whom she disclosed the reason for the visit.

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

It was reported to Community Care Licensing that Client 1 (C1) [LIC 811 Confidential Names List was provided to identify the client] was pushing one of the facility’s trash bins up the sloped driveway, lost his balance, and fell, causing C1 to hit his head, which resulted in a concussion.

The investigation revealed that on 5/19/2020, C1 was assisting staff with pushing the trash cans to the edge

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dawn Segura
LICENSING EVALUATOR SIGNATURE:	DATE: 09/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2023

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 5

Control Number 08-AS-20200603112940

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: 09/22/2023

NARRATIVE

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[2] of the driveway, which is on an incline. While pushing the recyclables bin, C1, who was accompanied by a staff member, lost his balance while trying to catch up with another staff member who was pushing a second trash bin further ahead. During the fall, C1’s left shoulder and head hit the ground. C1 was escorted back into the home, where abrasions and laceration that were sustained in the fall were cleaned. A short while later, C1 was evaluated by the facility’s nurse and, subsequently, transferred to the hospital. During the hospital visit, steri-strips were applied to the laceration, and a CT scan was performed, which indicated there was no additional injury or abnormal finding. C1 returned to the facility a few hours later with informational discharge paperwork.

Interviews conducted with facility staff, outside source, and facility and medical records reviewed during the investigation yielded that staff were present, supervising, and accompanying C1 the entire time that he was transferring the bin and while the fall occurred. The investigation did not yield evidence to conclude that C1’s fall or the resulting injuries were sustained as a result of neglect or lack of supervision on the part of facility staff.

The second allegation is that facility staff did not arrange necessary medical services for a client. It was reported that C1 was sitting on the toilet seat, went into a daze, and slid onto the floor, hitting his head on the toilet seat, which resulted in an unknown quantity of blood. A review of facility records reflected that, at approximately 5:27 AM, C1 experienced a fall while getting up from the toilet. According to the notes reviewed, staff went into the restroom to check on C1 after the fall. Prior to assisting C1 up, staff asked whether C1 was okay, to which C1, who was able to self-advocate, confirmed that he was okay. Staff conducted a body and head check, during which staff ran their hands around C1’s head applying pressure and asking if anything was hurting, to which C1 responded no. It was also documented that there were no visible marks at the time of the assessment. It was also noted that a little less than 10 minutes later, C1 complained of stomach cramps; however, there was no complaint of head or any other type of pain. Records reviewed reflect that C1 continued with his daily activities as normal. At approximately 8:41 AM, C1 was assessed by the facility’s nurse, and the assessment revealed slight tenderness (pain level 0 to 1) when touching the back of C1’s head, but no swelling or bruising. An abrasion to C1’s left elbow was detected and was treated with Neosporin. Based upon interviews and records reviewed, there was no indication that outside medical intervention was needed to address C1 following the fall.

SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dawn Segura
LICENSING EVALUATOR SIGNATURE:	DATE: 09/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 5

Control Number 08-AS-20200603112940

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: 09/22/2023

NARRATIVE

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[3] The third allegation is that facility staff neglected a client’s care needs. It was reported that C1 used a CPAP machine while sleeping. It was further that C1’s machine started short circuiting in the middle of March or early April of 2020. It was reported that the facility’s program director was informed; however, the machine was not replaced, no action was taken, and the machine began to give out electrical sparks on May 1, 2020. Interviews conducted during the investigation yielded that the CPAP machine that C1 was admitted into the home with was an old machine. Records reviewed and interviews conducted confirmed that the machine malfunctioned on or around April 30, 2023. In response, C1 was transported to the hospital, and records reflect that C1 experienced no injuries or consequences as a result of the machine’s malfunction. Records reflect that a new CPAP machine was ordered at that time or shortly before. Records and interviews also indicated that the new machine was delayed in arriving due to circumstances outside of the licensee’s control. Evidence revealed that once the machine malfunctioned, clearance was given for C1 to sleep without the use of the CPAP machine until the new machine arrived, and staff were instructed to monitor C1 closely while he slept. The investigation did not yield evidence to conclude that the licensee or facility staff did not take necessary action to address the client’s care needs or the need for a new CPAP machine.

The fourth allegation is that facility staff punished a client by withholding food. It was reported that Staff 2 (S2) saw Client 2 (C2) eating a small snack and told the client “you aren’t getting any dinner.” Reportedly, on another occasion, S2 told Staff 1 (S1) “don’t give C2 anything,” referring to food/drink because C2 did not participate in cleaning his own bed after a urinary incontinence incident. The investigation did not yield any evidence to corroborate the allegation.

The fifth allegation is that facility staff did not meet a client’s incontinent care needs. It was reported that C2 had an incontinence episode, and S2 refused to assist C2 with changing clothes and led C2 back to bed. A review of records maintained by the facility reflected that C2 has a documented history of urinary incontinence. Records and interviews revealed that C2 often urinated while in bed, and there were plans in place for staff to prompt C2 at regular intervals to get up and use the restroom. Interviews further revealed that C2 often refused staff promptings and often stayed in bed late into the day as a means of avoidance and a result of disrupted sleep caused by staff promptings throughout the night. Information obtained during the investigation indicates that staff made attempts, through ongoing prompting, to get C2 out of bed to prevent episodes of urinary incontinence. It was determined from information gathered during the investigation that C2, who, according to his Individual Behavior Supports Plan (IBSP), is able to advocate for himself, would

SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dawn Segura
LICENSING EVALUATOR SIGNATURE:	DATE: 09/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2023

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 08-AS-20200603112940

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: 09/22/2023

NARRATIVE

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[4] exercise his personal right in refusing to get out of bed before and after episodes of urinary incontinence. It was also documented in C2’s IBSP that a targeted goal was for C2 to participate in making his bed following an episode of urinary incontinence. The investigation did not yield evidence to conclude that C2 was led back to bed in soiled clothing or linen or that C2 was left in soiled clothing for extended periods of time because of lack of action on the part of facility staff, but that C2 exercised his personal right and chose to remain wet, in spite of attempts and/or efforts to convince C2 to do otherwise.

The sixth allegation is that facility staff mismanaged a client’s medication. It was reported that C1 was transported to urgent care by facility staff following the CPAP machine malfunction, and staff who transported C1 forgot two of C1’s medications at the facility. Reportedly, the staff called the facility and notified that the pills had been forgotten. It was reported that staff removed the medication from the packaging, discarded the pills, and documented that the pills had been administered, although they had not been administered to the client. Interviews conducted and records reviewed during the investigation did not produce evidence to corroborate the allegation.

The seventh allegation is that facility staff did not reassess a client following a change in condition. It was reported that, following C1’s fall in the restroom, C1’s baseline level of balance/coordination was impaired; however, C1’s care plan was not updated. LPA’s observation, records maintained relative to C1, and interview conducted yielded that C1 had an unsteady gait prior to the fall. Interview and records also revealed that, following the fall, C1 was assessed by the facility’s nurse, his physician was notified of the fall, and C1 was regularly monitored; however, the investigation did not produce evidence to conclude that the fall caused a change in C1’s condition that warranted a formal reassessment or change in C1’s level of care.

The eighth allegation is that facility staff did not follow reporting requirements. It was reported that C1 fell in the bathroom in May 2020, during which C1 hit his head and his arm; however, the incident was not reported to Community Care Licensing. It was confirmed during the investigation that the incident occurred. It was discovered through the course of the investigation that C1 was assessed by facility staff and the facility’s nurse following the fall. Evidence also indicates that C1’s physician was made aware, and it was determined that only 1^st aid care was needed to treat a skin tear on the elbow area of C1’s arm. There was no evidence obtained that indicated that the incident and resulting treatment that was needed and administered rose to the level of reporting to CCL as required by Title 22 regulation.

SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dawn Segura
LICENSING EVALUATOR SIGNATURE:	DATE: 09/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2023

LIC9099 (FAS) - (06/04)

Page: 5 of 5

Control Number 08-AS-20200603112940

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: 09/22/2023

NARRATIVE

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[5] Based upon a lack of evidence to corroborate the allegations, the allegations are unsubstantiated. This finding means that although the allegations may have happened or may be valid, there is not a preponderance of evidence to prove that the alleged violations occurred.

An exit interview was conducted with Morgan Davis, and copies of this report and Licensee Rights were provided to Morgan at the conclusion of the visit. Her signature on this report acknowledges receipt of copies of the report and the rights.

SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dawn Segura
LICENSING EVALUATOR SIGNATURE:	DATE: 09/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2023

LIC9099 (FAS) - (06/04)

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