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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374604208
Report Date: 03/27/2024
Date Signed: 03/27/2024 02:28:24 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
01/22/2021 and conducted by Evaluator Dawn Segura
COMPLAINT CONTROL NUMBER: 08-AS-20210122082238
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: 4DATE:
03/27/2024
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Ali Jaouhar, StaffTIME COMPLETED:
01:30 PM
ALLEGATION(S):
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Staff did not provide appropriate care and supervision to client.
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 Ali Jaouhar, Lead Behavioral Support Professional, to whom she disclosed the reason for the visit.

It was reported to Community Care Licensing that Client 1 (C1) [LIC 811 was provided to identify the client/staff], who requires total care and supervision, fell in the home at approximately 4:30 AM when left unsupervised by staff who was designated to provide one-to-one supervision to C1.

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

The investigation yielded that during the nocturnal shift of 1/15/2021 – 1/16/2021, at approximately 4:30 AM, while in bed, C1 had an accident in which C1 soiled the bed. Staff 1 (S1), who was assigned as the
Substantiated
Estimated Days of Completion: 0
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dawn Segura
LICENSING EVALUATOR SIGNATURE:

DATE: 03/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2024
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-20210122082238
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: 03/27/2024
NARRATIVE
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one-to-one staff for C1 during the shift, assisted C1 to get cleaned up following the accident. After C1 was cleaned, S1 retrieved clean linen to change the bed, during which time, C1 reportedly fell sideways from the bed to the floor and hit his/her head during the fall. Records reviewed noted that C1 was assessed by the lead staff on the shift, who determined that C1 appeared to be fine, and the facility’s nurse was contacted via telephone and informed of the incident. Staff put C1 back in bed for the rest of the shift.

Based upon evidence received and reviewed during the investigation, C1 was required to have 1:1 arm’s length supervision at all times, and evidence indicates that C1 was not being supervised at the time of the fall.

Considering the foregoing, the allegation is substantiated. This finding means that the preponderance of the evidence standard has been met and the allegation is valid. Deficiency is cited in accordance with California Code of Regulations, Title 22, Division 6, Chapter 8 and noted on the attached LIC 9099-D.

An exit interview was conducted with Ali Jaouhar, and copies of this report and Licensee/Appeal Rights (LIC 9058) were provided at the conclusion of the visit. Ali's signature below serves as acknowledgment of receipt of copies of the report and rights.
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dawn Segura
LICENSING EVALUATOR SIGNATURE:

DATE: 03/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 08-AS-20210122082238
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: 03/27/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/10/2024
Section Cited
CCR
80078(a)
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Responsibility for Providing Care and Supervision. The licensee shall provide care and supervision as necessary to meet the client's needs.

This requirement was not met as evidenced by:

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DIrector of Quality Assurance and Training informed LPA that communications have been updated so that all staff are notified via email, Teams, and verbal communication at the start of shift each time there is an update to C1's care needs/plan
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Based on interviews and records reviewed, the licensee did not provide supervision needed to meet the needs of 1 of 2 (C1) clients in care, which posed potential health and safety risks to a person in care.
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Director of Quality Assurance and Training offered to provide proof of staff training that has been provided to all staff on care and supervision of clients.
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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: 03/27/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 5
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
01/22/2021 and conducted by Evaluator Dawn Segura
COMPLAINT CONTROL NUMBER: 08-AS-20210122082238

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: 4DATE:
03/27/2024
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Ali Jaouhar, StaffTIME COMPLETED:
01:30 PM
ALLEGATION(S):
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9
Staff did not seek timely medical attention for client.
INVESTIGATION FINDINGS:
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13
Licensing Program Analyst (LPA) Dawn Segura conducted an unannounced visit to deliver investigative findings. LPA was granted entry into the facility and met with Ali Jaouhar, Lead Behavioral Support Professional, to whom she disclosed the reason for the visit.

It was reported to Community Care Licensing that Client 1 (C1), who requires total care and supervision, fell in the home at approximately 4:30 AM. Reportedly, following the fall, C1 was assessed by the facility’s nurse at 8:30 AM and transported to the hospital at 8:30 PM to be examined in response to the fall.

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

Unsubstantiated
Estimated Days of Completion: 0
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dawn Segura
LICENSING EVALUATOR SIGNATURE:

DATE: 03/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 08-AS-20210122082238
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: 03/27/2024
NARRATIVE
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The investigation yielded that, at approximately 4:30 AM, while Staff 1 (S1) turned away from C1 to retrieve clean linens, C1 fell onto the floor and reportedly hit his/her head during the fall. S1, who was serving as C1’s one-to-one staff at the time, summoned the Lead Behavioral Support Professional (Lead BSP), who was present in the facility at the time, to check C1’s body. According to evidence obtained, the facility’s nurse was contacted by the Lead BSP, via telephone, at approximately 4:55 AM and informed of the incident. During the call, the nurse advised staff to monitor C1 closely and that C1 would be assessed upon the nurse’s arrival at 7:00 AM. The nurse assessed C1 between 7:00 and 8:00 AM and determined that a hospital visit was not warranted. The client was later assessed by the facility’s mental health clinician, and the determination was made for C1 to be transported to the hospital for a medical evaluation. Hospital records reflect that C1 was evaluated at the hospital at 10:31 PM on 1/16/2021.

Records maintained by the facility and reviewed during the investigation reflect that C1 appeared to be fine when assessed by the Lead BSP immediately following the fall, and no apparent health concerns were observed. Additionally, hospital records reflect that, at the time of the visit, C1 presented with no complaints of head, neck, or back pain and had remained ambulatory since the time of the incident.

The investigation did not yield evidence to conclude that medical attention was not sought in a timely manner by facility staff. Accordingly, the allegation is unsubstantiated. This finding means that although the allegation may have happened or may be valid, there is not a preponderance of evidence to prove that the alleged violation occurred.

An exit interview was conducted with Ali Jaouhar, and copies of this report and Licensee Rights were provided to the staff at the conclusion of the visit. Ali's 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: 03/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5