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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 392700706
Report Date: 11/05/2021
Date Signed: 11/10/2021 11:43:51 AM

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
10/14/2021 and conducted by Evaluator Albert Johnson
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20211014110625
FACILITY NAME:MONTANA HOMESFACILITY NUMBER:
392700706
ADMINISTRATOR:JOHNSON, ALPHEREFACILITY TYPE:
735
ADDRESS:4442 MIST TRAIL DRTELEPHONE:
(209) 817-7190
CITY:STOCKTONSTATE: CAZIP CODE:
95206
CAPACITY:5CENSUS: 3DATE:
11/05/2021
UNANNOUNCEDTIME BEGAN:
01:58 PM
MET WITH:Susan ChankTIME COMPLETED:
03:29 PM
ALLEGATION(S):
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Staff spoke inappropriately towards a client while in care
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Johnson made an unannounced visit to the facility to deliver findings for the above allegation. LPA spoke with Administrator and explained the purpose of the visit.

Throughout the course of the investigation the Department interviewed staff and residents, toured the physical plant, and reviewed documentation pertinant to the allegations listed above.

Allegation: Staff speak inappropriately towards the residents while in care.


***Continuation on 9099-C***
Substantiated
Estimated Days of Completion: 0
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE:

DATE: 11/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/05/2021
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 3
Control Number 27-AS-20211014110625
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: MONTANA HOMES
FACILITY NUMBER: 392700706
VISIT DATE: 11/05/2021
NARRATIVE
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Based on records reviewed and interviews conducted, S1 spoke to R1 inappropriately on 6/15/2021. On 6/15/21, there was an incident with R1. R1 was yelling at his house mate and when S1 went upstairs to find out why he was yelling. R1 start yelling at S1 and S1 yelled back at him. S1 told R1 that he was a retard and that is why he is living at the facility. The Administrator, Kimberly Bishop reported that S1 was terminated the same day as this incident for making the derogatory comment to R1. S1 last day of work was on 6/15/2021. S1 submitted a letter of resignation on 6/26/2021. Evidence was provided to indicate the validity of the allegation above.

Based on interviews and records reviewed the Department finds the allegations to be Substantiated, meaning there was/is a preponderance of evidence that the event occurred.

Deficiencies are being cited as a result of today's visit.

Exit interview conducted, copy of report provided.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE:

DATE: 11/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/05/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 27-AS-20211014110625
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: MONTANA HOMES
FACILITY NUMBER: 392700706
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/05/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/05/2021
Section Cited
CCR
80072(a)(1)
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(a) Except for children’s residential facilities, each client shall have personal rights which include, but are not limited to, the following:
(1) To be accorded dignity in his/her personal relationships with staff and other persons.
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S1 was given training and refused to return to work after the incident. S1's last day of work was 6/15/2021.

No further action from the facility required
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This requirement was not met as evidenced by records reviewed and interviews conducted. S1 spoke to R1 inappropriately on 6/15/2021.
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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: Stephenie Doub
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE:

DATE: 11/05/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/05/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 3