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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 392700825
Report Date: 05/03/2022
Date Signed: 05/03/2022 03:59:33 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
05/02/2022 and conducted by Evaluator Maja Jensen
COMPLAINT CONTROL NUMBER: 27-AS-20220502125225
FACILITY NAME:CHAMPION RESIDENTIAL IIFACILITY NUMBER:
392700825
ADMINISTRATOR:BOYD, JAMESHAFACILITY TYPE:
735
ADDRESS:577 SUTHERLAND DR.TELEPHONE:
(209) 420-9932
CITY:STOCKTONSTATE: CAZIP CODE:
95210
CAPACITY:4CENSUS: 4DATE:
05/03/2022
UNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:TIME COMPLETED:
04:15 PM
ALLEGATION(S):
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Staff interacted inappropriately with resident(s) in care.
INVESTIGATION FINDINGS:
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On 5/3/22 Licensing Program Analyst (LPA) Maja Jensen arrived at facility to open a complaint investigation. LPA Jensen met with Administrator Jamesha Boyd and explained the purpose of today's visit.

LPA Jensen interviewed Administrator Jamesha Boyd who confirmed that on 4/29/22 a staff member had a verbal altercation with a resident. Other residents had returned from an outing and witnessed the incident. The Adminstrator was contacted and promptly arrived on scene and investigated the incident. The Administrator determined that the staff member reacted inappropriately and terminated him effective immediately. The Administrator reported the incident as required to the Regional Center and Community Care Licensing. LPA Jensen also reviewed the incident reports submitted. Based on LPA's review of the incident reports and interview with the Administrator which was conducted the preponderance of evidence standard has been met, therefore the above allegation is SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D.
An exit interview was conducted with Executive Director. A copy of this report and Appeal Rights given.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE:

DATE: 05/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2022
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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Control Number 27-AS-20220502125225
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 II
FACILITY NUMBER: 392700825
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/03/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/03/2022
Section Cited
CCR
80072(a)(1)
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Personal Rights

(a) Except for Children's residential facilituies, each client shall have persponal rights which include, but are not limited,the following:
(1) To be accorded dignity in his/her personal relationships with staff and other persons. The licensee did not meet this requirement based on:
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The staff member that interacted inappropriately has been terminated effective 4/29/22 therefore no further plan of correction is necessary
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As evidenced by the incident reports and interview with Administrator, on 4/29/22 a staff member yelled at a resident.
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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: Maja Jensen
LICENSING EVALUATOR SIGNATURE:

DATE: 05/03/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2