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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374604233
Report Date: 06/18/2024
Date Signed: 06/18/2024 02:11:15 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 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
06/13/2024 and conducted by Evaluator Tiffany Holmes
COMPLAINT CONTROL NUMBER: 08-AS-20240613151936
FACILITY NAME:TARLETON HOUSEFACILITY NUMBER:
374604233
ADMINISTRATOR:CESIAH SERRANOFACILITY TYPE:
735
ADDRESS:1650 TARLETON STTELEPHONE:
(619) 323-0804
CITY:SPRING VALLEYSTATE: CAZIP CODE:
91977
CAPACITY:6CENSUS: 4DATE:
06/18/2024
UNANNOUNCEDTIME BEGAN:
01:23 PM
MET WITH:Ashley Serrano, StaffTIME COMPLETED:
02:25 PM
ALLEGATION(S):
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Licensee did not meet staff-client ratio for clients in care.
Facility staff does not have required training
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Tiffany Holmes conducted a visit to commence a complaint investigation into the above identified allegation. LPA was granted entry into the facility by Ashley Serrano, Staff, to whom LPA disclosed the purpose of the visit. Community Care Licensing (CCL) has investigated the above-listed complaint allegation. The investigation consisted of a review of outside source records and interview of 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, the licensee was required by San Diego Regional Center to have a minimum of 363 hours for staff for the 4 clients.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Tiffany Holmes
LICENSING EVALUATOR SIGNATURE:

DATE: 06/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2024
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 3
Control Number 08-AS-20240613151936
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: TARLETON HOUSE
FACILITY NUMBER: 374604233
VISIT DATE: 06/18/2024
NARRATIVE
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Interviews conducted and a review of outside source records reflected that the hours reported did not meet the required staffing hours for a Level 4i facility and was missing documentation for staffing coverage of two overnight shifts within the specified week of March 31- April 16th, 2024 for San Diego Regional Center. Interviews revealed that time cards were reviewed and showed the missing staff to client ratio.

It was alleged that facility staff does not have required training. Documents reviewed and interviews revealed that the house manager has not completed the DSP1 training. Interviews also revealed the administrator has not completed ongoing training causing failure to comply with requirements for staff qualifications.
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 Ashley Serrano, staff and a copy of this report, and Licensee/Appeal Rights (LIC9058) were provided at the conclusion of the visit, their signature on this report acknowledges receipt of copies of the reports and the rights.
SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Tiffany Holmes
LICENSING EVALUATOR SIGNATURE:

DATE: 06/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3
Control Number 08-AS-20240613151936
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: TARLETON HOUSE
FACILITY NUMBER: 374604233
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/18/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/31/2024
Section Cited
CCR
80065(a)
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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:
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Licensee will provide new time cards/sheets and staff schedules to CCL for the month of June 2024 and July 2024 by 07/31/2024. POC due to CCL by 07/31/2024
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Based on interview and review of records, licensee did not have personnel sufficient in numbers to meet the needs of 4 of 4 (C1- C4) clients in care. This posed potential safety and personal rights violations to persons in care.
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Type B
07/31/2024
Section Cited
HSC
1569.626(a)
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Training Requirements for Direct Care Staff: All residential care facilities for the elderly shall meet the following training requirements, as described in Section 1569.625, for all direct care staff: This requirement was not met as evidenced by:
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The Licensee will obtain training for Staff to meet this requirement. Once completed, copies of certificates or certification from the Licensee that training has been completed will be sent to CCLD by POC due date, 07/31/2024
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Staff 1's date of hire was 05/01/23. Review of records show S1 does not have training specified in this section to meet the needs of 4 out of 4 clients (C1- C4). This poses a potential health and safety risk to the residents 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.
SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Tiffany Holmes
LICENSING EVALUATOR SIGNATURE:

DATE: 06/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3