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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 392700603
Report Date: 10/11/2023
Date Signed: 10/11/2023 12:58:48 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO AC/SC, 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
07/31/2023 and conducted by Evaluator Kesha Lewis
COMPLAINT CONTROL NUMBER: 27-AS-20230731142003

FACILITY NAME:AUSTIN ROAD HOMEFACILITY NUMBER:
392700603
ADMINISTRATOR:WARREN, KATHYFACILITY TYPE:
735
ADDRESS:16590 S AUSTIN RDTELEPHONE:
(209) 823-6061
CITY:MANTECASTATE: CAZIP CODE:
95336
CAPACITY:6CENSUS: 4DATE:
10/11/2023
UNANNOUNCEDTIME BEGAN:
10:55 AM
MET WITH:Melinda Womble TIME COMPLETED:
01:00 PM
ALLEGATION(S):
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Resident was abused while in care
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kesha Lewis arrived at the facility unannounced to deliver complaint findings for the above allegations. LPA was greeted by staff and Melinda Womble joined 10 minutes later. LPA explained the reason for the visit.

Allegation 1 Resident was abused while in care is SUBSTANTIATED Based on interviews and records reviewed, R1 was grabbed by the wrist by S1.

This agency has investigated the allegation and has found the allegation to be substantiated meaning that there was a preponderance of evidence to prove the allegation was true.

The following deficiency was cited per Title 22 Provision 6 of the CA Code of Regulations.

An exit interview was conduct. A copy of this report along with appeal rights was given.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Kesha Lewis
LICENSING EVALUATOR SIGNATURE:

DATE: 10/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 27-AS-20230731142003
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: AUSTIN ROAD HOME
FACILITY NUMBER: 392700603
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/11/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/11/2023
Section Cited
CCR
80072(a)(3)
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Personal Rights: 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, including but not limited to: interference with the daily living functions, including eating, sleeping,
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Facility has already compleated staff training, and involved staff have been terminated from the facility.
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or toileting; or withholding of shelter, clothing, medication or aids to physical functioning. This requirement was met as evidenced by statements and witnessed who observed staff member grab a resident by their wrist which poses a potential health, safety and personal 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: Kesha Lewis
LICENSING EVALUATOR SIGNATURE:

DATE: 10/11/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3