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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604208
Report Date: 06/19/2024
Date Signed: 06/19/2024 04:23:04 PM

Document Has Been Signed on 06/19/2024 04:23 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:LIBERTY TRANQUILITYFACILITY NUMBER:
374604208
ADMINISTRATOR/
DIRECTOR:		CYNTHIA RUIZFACILITY TYPE:
737
ADDRESS:1404 ASH STREETTELEPHONE:
(760) 625-5106
CITY:RAMONASTATE: CAZIP CODE:
92065
CAPACITY: 4CENSUS: 4DATE:
06/19/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:25 PM
MET WITH:Cynthia Ruiz, Program DirectorTIME VISIT/
INSPECTION COMPLETED:
04:25 PM
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Licensing Program Analyst (LPA) Dawn Segura conducted an unannounced Case Management - Incident visit. LPA identified herself and was granted entry into the facility by Cynthia Ruiz, with whom LPA met and discussed the purpose of the visit.

Today's visit was initiated in response to an SOC341 Report of Suspected Dependent Adult/Elder Abuse, which was received by Community Care Licensing (CCL) on 5/29/2024, in which licensee self-reported that Staff 1 (S1) spoke to Client 1 (C1) in an inappropriate manner. Licensee promptly conducted an internal investigation, the result of which was received by Community Care Licensing on 6/5/2024. Interviews conducted revealed that, on the afternoon of 5/27/2024, C1 was riding in the transportation vehicle while enroute from an outing. While sitting in the rear of the transportation van, C1 and S1 engaged in a verbal altercation, during which S1 used profanity while speaking directly to C1.

An SOC341 Report of Suspected Dependent Adult/Elder Abuse was also received on 6/5/2024, in which it was self-reported that there was alleged physical abuse of C1. Licensee conducted an internal investigation, the result of which was received by CCL on 6/13/2024. It was reported that on 5/30/2024, while C1 was napping, Staff 2 (S2) attempted to awaken C1 from his/her nap to administer medication. Reportedly, S2 tapped C1 three times on the arm; however, C1 did not wake up. According to the report, S2 then pulled C1 by his/her right arm, at which time C1 awakened. There were no injuries reported. There was not sufficient evidence obtained to conclude that S2 pulled C1 by the arm to awaken C1.

CCL also received an SOC341 Report of Suspected Dependent Adult/Elder Abuseon 6/5/2024, in which it was reported that S2 spoke to C1 in an inappropriate manner. Once made aware, Licensee conducted an internal investigation, the result of which was received by CCL on 6/14/2024. It was reported that while C1 was engaged in a resistive behavior, S2 yelled at C1 while also using profanity directed at C1. The investigation yielded video evidence to conclude that the reported event occurred a while ago.

SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dawn Segura
LICENSING EVALUATOR SIGNATURE: DATE: 06/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/19/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 06/19/2024
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During today’s visit, LPA performed a brief facility tour and welfare check, observing clients who were present during the visit. No safety concerns were noted. LPA also obtained a copy of a pertinent record.

Based on evidence provided, in response to two of the above identified incidents, a deficiency is being cited Per Title 22, Division 6, Chapter 8 of the California Code of Regulations and are listed on an LIC 809-D.

An exit interview was conducted, and this report was discussed with Cynthia Ruiz. Copies of the report and Licensee/Appeal Rights (LIC 9058 3/22) were provided to the Program Director, whose signature below acknowledges receipt of the rights and a copy of this report.

SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dawn Segura
LICENSING EVALUATOR SIGNATURE:

DATE: 06/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/19/2024 04:23 PM - It Cannot Be Edited


Created By: Dawn Segura On 06/19/2024 at 09:52 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: LIBERTY TRANQUILITY
FACILITY NUMBER: 374604208

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/19/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/25/2024
Section Cited
CCR
80065(l)

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Personnel Requirements. Personnel shall provide for the care and safety of persons without physical or verbal abuse, exploitation or prejudice.
This requirement was not met, as evidenced by:
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S1 and S2 have been terminated. Program Director stated that staff are required to complete training relative to client rights and reporting abuse by 6/21/2024. Program Director offered to provide proof of training to Community Care Licensing by the POC due date of 6/25/2024.
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Based on interviews conducted, the licensee did not ensure that 1 of 4 (C1) clients in care was provided care without verbal abuse. This posed potential personal rights risks to a person 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.
SUPERVISOR'S NAME:Lizzette Tellez
LICENSING EVALUATOR NAME:Dawn Segura
LICENSING EVALUATOR SIGNATURE:
DATE: 06/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/19/2024


LIC809 (FAS) - (06/04)
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