374604208-3-27-2024-08-AS-LTEZ-D3TNXE-20240329105057

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374604208
Report Date: 03/27/2024
Date Signed: 03/27/2024 02:31:20 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
01/04/2021 and conducted by Evaluator Dawn Segura

COMPLAINT CONTROL NUMBER: 08-AS-20210104133943

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:	03/27/2024
		UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Ali Jaouhar, Staff		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

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Client sustained unexplained bruising while in care.

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 (CCL) that a bruise approximately 4x4 inches was observed on the upper right back of C1 on 12/25/2020.

CCL has investigated the above-listed complaint allegation. The investigation consisted of a tour of the facility, interview of facility staff, and review of outside source record.

The investigation yielded that C1 was observed by facility staff with a bruise on the upper right side of his/her back and a rash on his/her thigh and abdomen. Hospital records reviewed during the investigation

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)

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Control Number 08-AS-20210104133943

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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documented that C1 was transported to the hospital on the night of 12/26/2020 for evaluation of the rash on C1’s thigh and abdomen. During the visit, C1 was assessed, and the rash was diagnosed as pruritus, which is an itchy feeling on the skin. Records reflect that the bruise on C1’s upper back was assessed, as well, during the visit. It is noted in the hospital records that the bruise reportedly resulted from a fall sustained by C1 a few days prior to the hospital visit, and C1 was experiencing no pain or tenderness in the area. It is documented in the hospital records that hospital personnel found no domestic concerns or psychosocial symptoms of note during the visit.

Based upon a lack of evidence to conclude that the bruising observed on C1 resulted from any action or inaction on the part of facility staff, 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)

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