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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 392700580
Report Date: 10/19/2022
Date Signed: 10/25/2022 02:01:02 PM

Unsubstantiated


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
09/06/2022 and conducted by Evaluator Albert Johnson
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20220906093319
FACILITY NAME:WALTERS RESIDENTIAL HOME CARE 3FACILITY NUMBER:
392700580
ADMINISTRATOR:CRISTOPHER WALTERSFACILITY TYPE:
735
ADDRESS:1335 MINE STTELEPHONE:
(510) 688-3552
CITY:STOCKTONSTATE: CAZIP CODE:
95206
CAPACITY:4CENSUS: 4DATE:
10/19/2022
UNANNOUNCEDTIME BEGAN:
09:52 AM
MET WITH:Walter'sTIME COMPLETED:
12:23 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff inappropriately pushed a client while in care
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Based on interviews conducted and records review, R1's IPP and intervention plans confirm that R1 is physically aggressive, quick tempered, impulsive and will assault staff and other residents in the home or at school. On the day of the incident R1 was incontinent and his roommate informed staff that his room was smelling, a request by R1's roommate to staff to have the room checked for the smells as a result R1 became agitated, broke his television, went to the bathroom and broke the bathroom door.

Staff held R1's wrist to stop the aggression and property destruction from continuing. R1 calmed down after sometime. There were no marks or bruising as a result of the staff holding R1's wrist and staff was able to continue with the care and supervision of R1 and other residents in care.

Records reviewed support a higher level of care to avoid R1 being a danger to himself or others. Medication records obtained confirmed that R1 is not taking a medication that has been part of his regiment. This medication has not been discontinued by R1's primary doctor.

As a result of this investigation, this Department found the allegation to be UNSUBSTANTIATED. A complaint allegation finding of Unsubstantiated meant that although the allegations may have happened or was valid, there was not a preponderance of the evidence to prove that the alleged violation occurred.
Unsubstantiated
Estimated Days of Completion: 0
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE:

DATE: 10/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
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