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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374604579
Report Date: 11/22/2024
Date Signed: 11/22/2024 06:27:43 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
08/16/2024 and conducted by Evaluator Marisela Garcia-Centeno
COMPLAINT CONTROL NUMBER: 08-AS-20240816095503
FACILITY NAME:HEALING ADULT GROUP CARE INC.FACILITY NUMBER:
374604579
ADMINISTRATOR:SAIF, SALLYFACILITY TYPE:
735
ADDRESS:3919 EL CANTO DR.TELEPHONE:
(248) 307-6966
CITY:SPRING VALLEYSTATE: CAZIP CODE:
91977
CAPACITY:6CENSUS: 6DATE:
11/22/2024
UNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Administrator, Sally SaifTIME COMPLETED:
02:45 PM
ALLEGATION(S):
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Staff over medicated client
Staff did not communicate effectively
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Marisela Garcia-Centeno conducted an unannounced visit to deliver investigative findings. LPA was allowed entry by Staff, Nargis Hamidi. LPA met with Administrator, Sally Saif, and shared findings over the telephone as she was not at the facility during the visit. Sally Saif arried at the facility at the end of the visit and signed the report.

The Department investigated the above-listed complaint allegations. The investigation consisted of an inspection of the facility, multiple observations, multiple interviews with staff, and outside sources, and a detailed review of relevant records.

On August 16, 2024, Community Care Licensing (CCL) received a complaint alleging that staff overmedicated client (C1), [an LIC811 Confidential Name List was provided to staff to identify C1].

Timeline:
It was specifically alleged that on Tuesday, August 13, 2024, at 9:30 a.m. C1 arrived at school overmedicated. This was the first day of school after the summer break. (Continue at LIC9099C)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Jennifer Lott
LICENSING EVALUATOR NAME: Marisela Garcia-Centeno
LICENSING EVALUATOR SIGNATURE:

DATE: 11/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2024
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 7
Control Number 08-AS-20240816095503
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: HEALING ADULT GROUP CARE INC.
FACILITY NUMBER: 374604579
VISIT DATE: 11/22/2024
NARRATIVE
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(continue from LIC9099)

During multiple interviews with outside sources, it was consistently stated that during breakfast, C1 was not able to hold their body upright while sitting at the table. According to outside sources, C1 was wobbling back and forth, side to side, and had to physically be held up to prevent C1 from falling over. The school nurse evaluated C1 and observed that C1’s eyes were dilated and that they were not able to stand or sit upright. During interviews with multiple outside sources, it was indicated that C1 had been attending the same school since September 28, 2020, (4.1 years ago) and school staff were very familiar with C1’s behavior. School staff determined that C1 was not acting their normal self and that C1 was not at their normal baseline. C1 was not able to participate in their normal school activities due to their physical and mental state. Based on their assessments, school staff called 911 and C1 was taken to the hospital by emergency medical personnel for immediate medical attention. School staff accompanied C1 to the hospital. During an interview with outside sources, it was indicated that nursing staff at the hospital reported that C1 had “elevated Depakote levels”. A detailed review of C1's medical records indicated that C1 was prescribed Depakote to treat a medical condition and to treat other psychiatric conditions. (Depakote is normally used to treat seizure disorders, and certain psychiatric conditions (manic phase of bipolar disorder). A review of the side effects of this medication was indicated on the warning signs as dizziness and drowsiness and if any of these side effects last or get worse, to consult with the doctor, or pharmacist promptly.

On Wednesday, August 14, 2024, C1 arrived at school in the same state as the prior day. After evaluating C1, the school nurse called 911 again and emergency medical personnel transported C1 to the hospital for immediate medical attention. A review of the discharge hospital notes indicated that C1 had altered mental status and was diagnosed with a bladder infection which is a type of urinary tract infection (UTI). C1 was prescribed antibiotics for the infection. In addition, the medication Depakote was adjusted, (decreased in dosage).

On Thursday, August 15, 2024, C1 arrived at school in a comatose state again. During interviews with outside sources, it was indicated that the school nurse, management, and teaching staff agreed that C1 was in an unstable condition to attend school. (Continue at LIC9099C)
SUPERVISORS NAME: Jennifer Lott
LICENSING EVALUATOR NAME: Marisela Garcia-Centeno
LICENSING EVALUATOR SIGNATURE:

DATE: 11/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 08-AS-20240816095503
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: HEALING ADULT GROUP CARE INC.
FACILITY NUMBER: 374604579
VISIT DATE: 11/22/2024
NARRATIVE
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(continue from LIC9099C)

C1 was sent back to the facility by school transportation services and the school nurse followed the school bus to ensure C1 was transported safely back to the facility.

On Friday, August 16, 2024, during interviews with outside sources, it was indicated that school transportation services were instructed not to pick up C1 from the facility until the school received a doctor’s note stating that C1 was able to return to school. A staff member from the facility drove C1 to school to drop them off. Despite school staff requesting staff not to leave C1 at the school until the school nurse had the opportunity to complete an assessment, the staff left C1 at the school. It was indicated that a note from the emergency room department was presented stating that C1 could return to school. During interviews with outside sources, it was indicated that C1 was wobbling back and forth throughout the morning C1’s gait was unsteady, and they were not able to eat solid foods, and fluid intake was minimal. Outside sources stated that C1’s head was bent to the point that C1’s chin was resting on their chest and were not able to lift to drink water. The school nurse evaluated and determined that C1 should be seen by their primary care physician to assess their ability to eat safely. The school staff sent a note to the facility administrator of their assessment and recommendation.

On Monday and Tuesday, August 19 - 20, 2024, per interviews with outside sources it was indicated that C1 arrived at school and was able to walk off the bus, however, C1 was still very wobbly while walking or sitting upright. C1 spent the majority of the day lying down, C1 was not able to eat more than 1 - 2 bites during breakfast and lunch. C1 only consumed 1-2 sips of water all day.

On Wednesday, August 21, 2024, from 10:15 a.m. to 12:20 p.m. during a collateral visit to the school, LPA observed C1 bent over and walking wobbly, C1’s gait was unsteady. C1 was observed walking in an uncoordinated unsteady manner. C1 was looking down the entire visit and never made eye contact. LPA attempted to get C1’s attention to no avail. C1’s head was observed bent forward with their chin resting on their chest and were not able to lift their head to drink water. With assistance, (it required two (2) persons, one staff was helping with the feeding, and one staff member was helping C1 keep their head in the upright position). C1 was observed eating one teaspoonful of apple sauce and one teaspoonful of noodles with hand-over-hand assistance. (Continue at LIC9099C)
SUPERVISORS NAME: Jennifer Lott
LICENSING EVALUATOR NAME: Marisela Garcia-Centeno
LICENSING EVALUATOR SIGNATURE:

DATE: 11/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 7
Control Number 08-AS-20240816095503
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: HEALING ADULT GROUP CARE INC.
FACILITY NUMBER: 374604579
VISIT DATE: 11/22/2024
NARRATIVE
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(continue from LIC9099C)

C1 had their eyes closed while chewing their food. C1 was observed to be sleepy, dizzy, and not alert. C1 remained in a bent-over position and put their head down on top of the table. C1 with assistance walked over to the multipurpose room where C1 laid down on the floor and fell asleep on top of a floor mat. During interviews, school staff stated that this was not C1’s typical behavior. School staff indicated that C1 would eat normal-sized portions of noodles as it was one of C1’s favorite meals. Note: during two (2) visits conducted at the facility for an unrelated case, on July 3, 2024 and July 25, 2024, LPA observed C1 walking around with a steady gait throughout the facility without assistance.

On Thursday, August 22, 2024, per interviews with outside sources, C1 arrived at school in a very lethargic manner. While sitting upright in a chair, C1 suddenly fell off the chair on their right side and fell to the ground. School staff stated that C1 was assessed and no serious injuries were sustained.

Friday, August 23, and Monday, August 26, 2024, C1 was absent from school. During interviews with outside sources, it was indicated that facility staff reported to the school that C1 was sent to the emergency room and that the doctor had decreased C1’s medications and facility staff were keeping C1 at the facility for monitoring and observation until C1 was feeling better before returning to school.

Follow-up interviews conducted in early October 2024 with outside sources, it was indicated that C1 had been doing much better at school and was back at baseline when C1 returned to school in September 2024. On October 9, 2024, during a collateral visit at the school, C1 was observed walking unassisted with a steady/stable gait. C1 was observed standing and sitting upright without assistance. In addition, C1 was observed alert and with their head in the upright position.

Interviews with staff disclosed that during the July 2024 school break, staff reached out to the psychiatrist requesting an increase in the Depakote medication dosage because C1 was having altered and aggressive behavior towards staff and clients. Staff stated that C1's medication dosage was increased to reduce the altered behaviors. A review of the medication administration records indicated that staff administered the medication as prescribed. (Continue at LIC9099C)
SUPERVISORS NAME: Jennifer Lott
LICENSING EVALUATOR NAME: Marisela Garcia-Centeno
LICENSING EVALUATOR SIGNATURE:

DATE: 11/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 7
Control Number 08-AS-20240816095503
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: HEALING ADULT GROUP CARE INC.
FACILITY NUMBER: 374604579
VISIT DATE: 11/22/2024
NARRATIVE
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(continue from LIC9099C)

Staff stated they observed that C1’s behavior became less aggressive. Although staff were following the doctor’s orders, staff should have actively and regularly observed C1 for changes in physical, mental, emotional, and social functioning and bring observed changes to the attention of C1’s physician. Instead, staff continued to medicate C1 according to the doctor’s orders despite the observed side effects (dizziness and drowsiness) C1 was displaying. A review of the warning side effects for the medication indicated that if any of the side effects last or get worse, to consult the attending physician, or pharmacist promptly. In addition, staff continued to send C1 to school despite displaying the negative side effects. During interviews, staff stated they had reached out to the psychiatrist and medical provider regarding C1’s change in condition, on 8/27/24, 8/28/24, and 9/12/24 during the period C1 was attending school in an over medicated state. Note: Only one (9/12/24) of the three follow-up visits was an in-person visit where C1 was physically evaluated by a physician.

It was also alleged that staff did not communicate effectively. It was specifically alleged that school personnel were not able to get in touch via telephone/text with facility staff during several of the emergency incidents involving C1 at school. For instance, on August 13, 2024, school staff called and sent multiple messages to facility staff to no avail. A review of the messages sent to the facility administrator in the morning to notify them of the 911 call and that C1 had been transported to the hospital showed the administrator's reply later in the afternoon. The same situation occurred on August 14, 2024; the school personnel was not able to get in touch with the administrator promptly. In addition, on August 15, 2024, when school personnel transported C1 back to the facility, staff were not present at the facility, and the school nurse and bus driver waited outside the facility for an extended period for facility staff to arrive. During interviews with facility staff, it was indicated that staff were not scheduled to work or be present at the facility when the clients attended school/day programs. The facility administrator stated that they normally attend to phone messages promptly and denied not being accessible via telephone. CCL had similar experiences with difficulties getting in touch with the administrator. LPA attempted three (3) visits at the facility on July 3, 25, and August 21, 2024, there were no staff present at the facility when the LPA arrived, and had a difficult time getting in touch with the facility administrator via telephone. During all three visits, the facility administrator eventually called back, and LPA was able to complete the visit at the facility 2- 3 hours after the attempted visit. (Continue at LIC 9099C)
SUPERVISORS NAME: Jennifer Lott
LICENSING EVALUATOR NAME: Marisela Garcia-Centeno
LICENSING EVALUATOR SIGNATURE:

DATE: 11/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 7
Control Number 08-AS-20240816095503
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: HEALING ADULT GROUP CARE INC.
FACILITY NUMBER: 374604579
VISIT DATE: 11/22/2024
NARRATIVE
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(continue from LIC9099C)


The Department has investigated the above-mentioned allegations and has found that there was sufficient evidence to corroborate the allegations. Therefore, these allegations are deemed to be substantiated. A substantiated finding means the allegation is valid because the preponderance of the evidence standard has been met. Deficiencies were cited per Title 22, Division 6, Chapter 8 of the California Code of Regulations and are listed on LIC 9099-D. A plan of correction was developed with Administrator, Sally Saif, via telephone.

An exit interview was conducted with Administrator, Sally Saiff over the telephone. A copy of this report, LIC 9099D, and LIC811, confidential list form along with Licensee/Appeal Rights (LIC 9058 03/22) were provided to Saif at the conclusion of the visit..
SUPERVISORS NAME: Jennifer Lott
LICENSING EVALUATOR NAME: Marisela Garcia-Centeno
LICENSING EVALUATOR SIGNATURE:

DATE: 11/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2024
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 08-AS-20240816095503
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: HEALING ADULT GROUP CARE INC.
FACILITY NUMBER: 374604579
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/22/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type B
12/23/2024
Section Cited
CCR
85075.4
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85075.4(a)(c) Observation of the Client The licensee shall regularly observe each client ...... The licensee shall bring observed changes, ....deterioration of health condition, to the attention of the client's physician. The licensee did not ensure staff did not overmedicate Client (C1) by regularly observing for changes in condition. This requirement was not met as evidenced by:
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LIcensee agreed to conduct in service training by an outside provider to ensure staff provide immediate medical attention to clients in care when change in condition occurs. Licensee agreed to submit documentation for inservice training by POC date of 12/23/2024.
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Based on observations, interviews with staff, and outside sources, the licensee did not ensure C1 was not overmedicated while in care. This posed a potential health risk to one (1) of six (6) clients in care.
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Deficiency Dismissed
Type B
12/23/2024
Section Cited
CCR
85072(b)(3)
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85072(b)(3) Personal Rights
The licensee shall insure ....
To have communications to the facility from his/her relatives or authorized representative answered promptly and completely. The licensee did not ensure staff communicated effectively with authorized representative. This requirement was not met as evidenced by:
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LIcensee agreed to conduct in service training by an outside provider to ensure staff adhere to all personal rights as it relates to communication and accessibility. Licensee agreed to submit documentation for inservice training by POC date of 12/23/2024.
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Based on observations, interviews with staff and outside sources, the licensee did not ensure staff communicated effectively with (C1’s) authorized representative. This posed a potential personal right risk to one (1) of six (6) clients 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: Jennifer Lott
LICENSING EVALUATOR NAME: Marisela Garcia-Centeno
LICENSING EVALUATOR SIGNATURE:

DATE: 11/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2024
LIC9099 (FAS) - (06/04)
Page: 7 of 7