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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374604282
Report Date: 03/10/2022
Date Signed: 04/27/2022 08:40:50 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
09/28/2021 and conducted by Evaluator Tiffany Holmes
COMPLAINT CONTROL NUMBER: 08-AS-20210928163937
FACILITY NAME:ABIGAIL'S HOMES IIIFACILITY NUMBER:
374604282
ADMINISTRATOR:GONZALEZ, BRENDA ABIGAILFACILITY TYPE:
735
ADDRESS:2505 ARCADIA AVETELEPHONE:
(619) 439-7791
CITY:LEMON GROVESTATE: CAZIP CODE:
91945
CAPACITY:4CENSUS: 2DATE:
03/10/2022
UNANNOUNCEDTIME BEGAN:
11:40 AM
MET WITH:Raquel Garcia, AdministratorTIME COMPLETED:
12:30 PM
ALLEGATION(S):
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Resident sustained an injury while in care
Staff did not prevent residents from engaging in a physical altercation
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Tiffany Holmes conducted an unannounced visit to close out a complaint. LPA identified herself, was granted entry, and stated the purpose of the visit to Raquel Garcia, Administrator. During the investigation, LPA toured the facility, conducted interviews and conducted a records review. It was alleged that resident sustained an injury while in care. A review of facility records show Incident reports received show these two clients have a history of similar behaviors. On June 15, 2021, C1 attacked C2 with no further action or follow up by the facility. On August 11, 2021, C2 kicked C1 and there was no further action or follow up by the facility. The incident on September 25, 2021 is now the third incident in which C1 and C2 engaged in behaviors, and the investigation revealed no actions have been taken, even with two previous documented similar incidents.

*This is an amended report from 03/10/2022 (9099D page)*
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Tiffany Holmes
LICENSING EVALUATOR SIGNATURE:

DATE: 04/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/27/2022
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-20210928163937
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: ABIGAIL'S HOMES III
FACILITY NUMBER: 374604282
VISIT DATE: 03/10/2022
NARRATIVE
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Interviews revealed on September 25, 2021 that Client 1(C1) called the administrator to ask about a visit with their family and found out the visit was for the next weekend. Interviews revealed Client 2 (C2) asked C1 about visiting their family. C1 got agitated with C2 and jumped on C2. C1 began to choke C2, pull C2’s hair, and bit C2 in the face causing injury on left cheek and on the left hand. Staff was able to separate the two and 911 was called. Interviews revealed staff sent C2 to their room and stayed with C1 until police arrived. The police department with PERT (Psychiatric Emergency Response Team) arrived. Interviews revealed both clients were escorted to the hospital. C1 was sent to the behavioral unit on a 51/50 hold and C2 was sent to be observed by medical staff for their injuries.

It was alleged that staff did not prevent residents from engaging in a physical altercation. Interviews revealed the two clients were in the living room and the staff was in the kitchen doing the dishes. Individual Program Plan for C2 revealed that C2 needs 24/7 supervision and line of sight supervision. Interviews with staff revealed that on 09/25/2021, staff heard C2 scream which is usual for C2 since C2 screams for attention. When the staff walked into the living room, staff observed the altercation between the clients. C2 kicked C1 and C1 kicked C2 back and began to pull C2s hair and choke them. Staff didn’t prevent the altercation from occurring due to staff being in the kitchen at the time and not supervising the clients.

Based on the evidence obtained from the investigation, the above-mentioned allegations are substantiated. The allegations are valid because the preponderance of the evidence standard has been met.

An exit interview was conducted with Raquel Garcia. A copy of this report and Licensee Appeal Rights (9058 01/16) were emailed to Administrator after the conclusion of the visit, LPA Holmes requested an electronic message reply to confirm receipt of these documents.
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Tiffany Holmes
LICENSING EVALUATOR SIGNATURE:

DATE: 03/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 08-AS-20210928163937
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: ABIGAIL'S HOMES III
FACILITY NUMBER: 374604282
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/10/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/11/2022
Section Cited
CCR
80072(a)(1)
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Except for children’s residential facilities, each client shall have personal rights which include, but are not limited to, the following: (1) To be accorded dignity in his/her personal relationships with staff and other persons.
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Licensee will speak with all staff regarding clients personal rights by 03/11/2022. Licensee will also have training on personal rights by an outside resourceon 03/18/2022.
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This requirement was not met as evidenced by interviews showing 1 out of 2 clients failed to treat another client with dignity. This posed an immediate personal rights violation to resident in care
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Type A
03/11/2022
Section Cited
CCR
80065(a)
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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.
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Licensee will change house duties to occur in the evenings when the clients are going to bed. Licensee will go over this new plan with all staff by 03/11/2022.
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This requirement was not met as evidenced by interviews showing S1 failed to appropriately supervise 2 out of 2 clients. This posed an immediate personal rights violation to resident in care.

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Licensee will also have training on supervision completed by 03/18/2022 by an outside resource
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: Simon Jacob
LICENSING EVALUATOR NAME: Tiffany Holmes
LICENSING EVALUATOR SIGNATURE:

DATE: 04/27/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/27/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3