<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374604477
Report Date: 12/03/2024
Date Signed: 01/03/2025 03:10:12 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
11/26/2024 and conducted by Evaluator Dang Nguyen
COMPLAINT CONTROL NUMBER: 08-AS-20241126170932
FACILITY NAME:SCARLETT'S CAREFACILITY NUMBER:
374604477
ADMINISTRATOR:SORENSON, BRADLEYFACILITY TYPE:
735
ADDRESS:1024 NEPTUNE DRIVETELEPHONE:
(619) 500-5339
CITY:CHULA VISTASTATE: CAZIP CODE:
91911
CAPACITY:4CENSUS: 3DATE:
12/03/2024
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:House Manager Carmila "Starr" Austin and Administrator Monica McDadeTIME COMPLETED:
06:15 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Licensee's staff physically abused client.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
[This report was originally authored on 12/03/2024. An amended version of the report was personally served to Licensee on 01/03/2025].

Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced visit to commence a Complaint Investigation regarding the above allegation. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with House Manager Carmila "Starr" Austin. LPA also met with Administrator Monica McDade, who arrived later during the visit.

The Complainant alleged that on date in mid-November 2024, Licensee’s staff, Staff #1 (S1), physically abused Client #1 (C1). [See LIC811 Confidential Names List for a description of select person identifiers used in this report.] CCLD’s investigation involved an unannounced facility tour/welfare check and review of pertinent care and personnel records. LPA also reviewed video evidence and interviewed all clients in care, all facility staff, and outside sources. [CONTINUED ON LIC 9099-C, 1 of 2]
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 12/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2024
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-20241126170932
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: SCARLETT'S CARE
FACILITY NUMBER: 374604477
VISIT DATE: 12/03/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
[CONTINUED FROM LIC 9099] Per C1’s latest LIC602 Physician’s Report, C1 was diagnosed with Down Syndrome and Agitation. According to C1’s Individual Program Plan (IPP) from San Diego Regional Center (SDRC), C1 was diagnosed with Down Syndrome, Mild Intellectual Disability, and Asthma. C1’s latest quarterly behavioral consulting report showed that C1 was also recently diagnosed with Dementia.

LPA obtained video footage showing S1 standing beside C1, forcefully pushing a pillow into their face, while C1 was yelling/screaming. Multiple interviews aligned to positively identify S1 and C1 as the respective persons depicted in the video. LPA interviewed multiple witnesses, who corroborated this incident of abuse had occurred and that S1 was the perpetrator.

During today’s visit, C1 did not have any bruising or sign of injury on their face, neck, or lower arms. C1 gave consent to LPA, who accompanied by facility staff, inspected the skin on C1’s upper body and lower legs. LPA found signs of bruises which were yellowing/fading. LPA asked C1 about the incident and the origin of said bruises, but C1 was not able to successfully answer LPA’s questions, even when they were rephrased in simple/binary format. Manager interview, corroborated by SDRC and third-party behavioral consulting documentation, showed C1 sometimes had emotional outbursts, physical aggression, and “self-injurious behavior.”

The other two clients in care, Client #2 (C2) and Client #3 (C3), were able to be successfully interviewed. Both told LPA that no staff, including S1, had abused them since they moved into the facility. Interviews of facility staff and an outside source also showed: There was a separate incident where Staff #2 (S2) used a water bottle with a squirt nozzle to spray C1’s chest during one of C1’s episodes of aggressive outburst/behavior. S2 said C1 was afraid of water and admitted to doing this once.

Based on records and interviews, a preponderance of evidence exists to show that S1 physically abused C1, and that S2 also violated C1’s personal rights via a punitive action. There is no evidence to conclude either incident directly resulted in bruising or injury to C1’s body. The allegation is therefore Substantiated (but no immediate civil penalty was charged). A deficiency was cited per California Code of Regulations, Title 22 (refer to the attached LIC 9099-D page). A Plan of Correction was jointly developed with the Licensee.

An exit interview was conducted with McDade, to whom a copy of this report, the LIC 9099-D page, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided.
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 12/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 08-AS-20241126170932
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: SCARLETT'S CARE
FACILITY NUMBER: 374604477
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/03/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/03/2024
Section Cited
CCR
80072(a)(3)
1
2
3
4
5
6
7
80072 Personal Rights: “(a) …each client shall have personal rights which include, but are not limited to, the following: (3) To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse, or other actions of a punitive nature…” This requirement was not met, as evidenced by:
1
2
3
4
5
6
7
Licensee terminated S1’s employment on 12/03/2024, based on the evidence collected, resolving the immediate risk. Licensee subsequently terminated S2’s employment on 12/05/2024. Licensee also agreed to conduct a training in-service for all remaining staff on Client’s Personal Rights (using forms DSP 304 and LIC613 which LPA provided). Licensee agreed to E-mail a copy of S1’s termination paperwork and a copy of the training sign-in sheet to LPA, by 01/03/2025.
8
9
10
11
12
13
14
Based on records, interviews, and video, Licensee did not ensure that 1 of 3 clients (C1) was free from corporal or unusual punishment, intimidation, mental abuse, or other actions of a punitive nature. This posed an immediate health, safety, and personal rights risk to persons in care.
8
9
10
11
12
13
14
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: Dang Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 12/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3