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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 392700539
Report Date: 11/09/2022
Date Signed: 11/09/2022 03:18:42 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, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/30/2022 and conducted by Evaluator Michael Bilger
COMPLAINT CONTROL NUMBER: 27-AS-20220930094236
FACILITY NAME:CHAMPION RESIDENTIALFACILITY NUMBER:
392700539
ADMINISTRATOR:BOYD, JAMESHAFACILITY TYPE:
735
ADDRESS:481 SPRING RIVER CIRCLETELEPHONE:
(510) 815-8570
CITY:STOCKTONSTATE: CAZIP CODE:
95210
CAPACITY:4CENSUS: 3DATE:
11/09/2022
UNANNOUNCEDTIME BEGAN:
01:21 PM
MET WITH:Jamesha BoydTIME COMPLETED:
03:45 PM
ALLEGATION(S):
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Facility staff was verbally aggressive towards resident
INVESTIGATION FINDINGS:
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On 11/9/22 at 1:21pm, licensing program analyst (LPA) Michael Bilger arrived unannounced to continue complaint investigation and deliver findings for the allegation noted above. LPA met with Administrator Jamesha Boyd via phone and explained the purpose of the visit. Administrator gave permission for house manager to sign in her absence. LPA interviewed resident 5 (R5) on 11-9-22. On 10-17-22, LPA interviewed R2, R3, and R4, as well as Staff2 (S2), S3, and S4. Additionally, LPA interviewed Administrator and S1 on 10-4-22. LPA also interviewed additional witnesses regarding the above allegation and conducted an observation at the facility where alleged incident took place. During investigation, LPA reviewed facility file documentation including physician’s report, individualized program plan (IPP), incident report, and staffing records.
Based on interviews conducted, it was determined that on 9-27-22, S1 arrived at a day program to transport R1 to facility. During S1’s attempt to transfer resident, multiple witnesses stated an observation of S1 using aggressive verbalization toward R1 which included foul language. {Cont. on 9099C}
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE:

DATE: 11/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2022
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 5
Control Number 27-AS-20220930094236
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: CHAMPION RESIDENTIAL
FACILITY NUMBER: 392700539
VISIT DATE: 11/09/2022
NARRATIVE
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 R1’s reactions were described as being frightful and intimidated. Based on the information consistent among the multiple witness accounts, it is determined that the preponderance of evidence standard is met, therefore, this allegation is SUBSTANTIATED.

Based on this investigation, citation is issued under Title 22, Division 6 and noted on LIC 9099D. An exit interview was conducted with Jamesha Boyd and a copy of this report was left with Jamesha. Appeal rights provided.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE:

DATE: 11/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 27-AS-20220930094236
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: CHAMPION RESIDENTIAL
FACILITY NUMBER: 392700539
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/09/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/21/2022
Section Cited
CCR
80072(a)(3)
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80072(a)(3). Personal Rights. (a) …each client shall have personal rights which include, but are not limited to, the following: (3) To be free from...humiliation, intimidation, ridicule... or other actions of a punitive nature… This requirement was not met as evidenced by:
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Licensee will conduct staff training on personal rights of residents including regulation 80072(a)(3) and submit proof of completed training to LPA by POC due date.
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 Based on interviews and record reviews, facility staff member used aggressive verbalization including foul language towards R1 during an encounter. This posed a potential health, safety, and resident rights risk to 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: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE:

DATE: 11/09/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/30/2022 and conducted by Evaluator Michael Bilger
COMPLAINT CONTROL NUMBER: 27-AS-20220930094236

FACILITY NAME:CHAMPION RESIDENTIALFACILITY NUMBER:
392700539
ADMINISTRATOR:BOYD, JAMESHAFACILITY TYPE:
735
ADDRESS:481 SPRING RIVER CIRCLETELEPHONE:
(510) 815-8570
CITY:STOCKTONSTATE: CAZIP CODE:
95210
CAPACITY:4CENSUS: 3DATE:
11/09/2022
UNANNOUNCEDTIME BEGAN:
01:21 PM
MET WITH:Jamesha BoydTIME COMPLETED:
03:45 PM
ALLEGATION(S):
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2
3
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9
Facility staff was rough handling a resident
INVESTIGATION FINDINGS:
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On 11/9/22 at 1:21pm, licensing program analyst (LPA) Michael Bilger arrived unannounced to continue complaint investigation and deliver findings for the allegation noted above. LPA met with Administrator Jamesha Boyd via phone and explained the purpose of the visit. Administrator gave permission for house manager to sign in her absence. LPA interviewed resident 5 (R5) on 11-9-22. On 10-17-22, LPA interviewed R2, R3, and R4, as well as Staff2 (S2), S3, and S4. Additionally, LPA interviewed Administrator and S1 on 10-4-22. LPA also interviewed additional witnesses regarding the above allegation and conducted an observation at the facility where alleged incident took place including a review of camera footage containing R1 and alleged perpetrator from 9-27-22. . During investigation, LPA reviewed facility file documentation including physician’s report, individualized program plan (IPP), incident report, and staffing records.

{Cont. on 9099C}
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE:

DATE: 11/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 27-AS-20220930094236
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: CHAMPION RESIDENTIAL
FACILITY NUMBER: 392700539
VISIT DATE: 11/09/2022
NARRATIVE
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Based on observations conducted as noted above, it was determined that on 9-27-22, R1 was being led out of day program by S1 in an attempt to transport R1 back to facility. Based on interview, one witness stated S1 handled R1 in an aggressive manner which included pulling R1 to S1’s car forcefully. A review of camera footage as noted above revealed S1 holding R1’s arm while walking with R1 to S1’s car with slight intermittent pull back from R1. Based on camera footage review, it was determined that rough handling of R1 could not be positively identified. Based on interviews conducted, there were no additional witnesses to alleged incident. As a result, the preponderance of evidence standard is not met. Therefore, this allegation is UNSUBSTANTIATED.

An exit interview was conducted with Jamesha Boyd and a copy of this report was left with Jamesha.. Appeal rights provided.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE:

DATE: 11/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 5