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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374604585
Report Date: 10/01/2024
Date Signed: 10/01/2024 03:04:39 PM

Unsubstantiated


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
01/10/2024 and conducted by Evaluator Tiffany Holmes
COMPLAINT CONTROL NUMBER: 08-AS-20240110105247
FACILITY NAME:NOR LIVING 6, LLCFACILITY NUMBER:
374604585
ADMINISTRATOR:RZOK, NAJAHFACILITY TYPE:
735
ADDRESS:811 ELKELTON BLVD.TELEPHONE:
(619) 335-0566
CITY:SPRING VALLEYSTATE: CAZIP CODE:
91977
CAPACITY:6CENSUS: 4DATE:
10/01/2024
UNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Edgar Casillas, StaffTIME COMPLETED:
09:25 AM
ALLEGATION(S):
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Client sustained unexplained injuries while in care
Staff did not ensure reporting requirements were followed
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA)Tiffany Holmes conducted an unannounced complaint visit to the facility to deliver findings on the above-mentioned allegations. LPA gained access to the facility, identified herself, and met with Edgar Casillas, Staff to discuss the purpose of the visit.

LPA conducted the initial investigation visit on 12/05/2023 and was able to interview clients, facility staff, and outside sources. LPA also reviewed records, and conducted a physical inspection of the facility. It was alleged that the client sustained unexplained injuries while in care. Interviews revealed that on December 28, 2023 Client 1 (C1) was having a behavior and the staff was assisting them. During this behavior staff turned around for 2 seconds to ask another staff a question and C1 started to make noise and kick the walls and punched holes in the wall. Interviews revealed C1 grabbed staff's 1 (S1) wrists and twisted them twice. On the same day C1 went in to the hospital on a 51 /50 hold.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Tiffany Holmes
LICENSING EVALUATOR SIGNATURE:

DATE: 10/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/01/2024
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 2
Control Number 08-AS-20240110105247
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: NOR LIVING 6, LLC
FACILITY NUMBER: 374604585
VISIT DATE: 10/01/2024
NARRATIVE
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 Interviews revealed there were two staff and one staff was making sure the other client was safe. Interviews revealed the second staff called Sonny the house manager, the PERT team came and the fire dept came and they took C1 to the hospital.

It was alleged that staff did not ensure reporting requirements were followed. Interviews revealed staff did ensure reporting requirements were followed by filling out the incident reports and sending them to Community Care Licensing (CCL) and San Diego Regional Center (SDRC). Interviews revealed after every incident there is an incident report filled out and sent to the reporting party and to the agencies. Interviews revealed there is a report process where the staff explain the situation to the house manager and they write up the incident report and then management will approve it. Interviews with an outside stated all incidents were reported.

Based on the evidence obtained from interviews, the complaint allegations of the client sustained unexplained injuries while in care and staff did not ensure reporting requirements were followed is unsubstantiated; as there is not a preponderance of evidence to prove the alleged violations did or did not occur.

An exit interview was conducted with Edgar Casillas, Staff and a copy of this report along with Licensee/Appeal Rights (LIC 9058 01/16) was provided at the conclusion of the visit
SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Tiffany Holmes
LICENSING EVALUATOR SIGNATURE:

DATE: 10/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/01/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2