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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 392701118
Report Date: 09/27/2023
Date Signed: 10/03/2023 05:29:08 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
06/06/2023 and conducted by Evaluator Charlie Yang
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20230606120748
FACILITY NAME:WALTERS RESIDENTIAL HOME CARE 4FACILITY NUMBER:
392701118
ADMINISTRATOR:KOAYEN, TANNEHFACILITY TYPE:
735
ADDRESS:4011 OAK VALLEY RDTELEPHONE:
(510) 688-3552
CITY:STOCKTONSTATE: CAZIP CODE:
95205
CAPACITY:4CENSUS: 4DATE:
09/27/2023
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Tanneh KoayenTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Staff inappropriately restrained resident
INVESTIGATION FINDINGS:
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Unannounced complaint visit made out to this facility on 09/27/2023 and this Licensing Program Analyst (LPA) was met by the facility designated Administrator, Tanneh Koayen, who was briefly interviewed at this time.
Current census was 4 residents.
The purpose of this visit was to deliver the findings of this complaint investigation to the facility and it's representatives at this time.
Based on interviews and a review of the forms and documents that were gathered during the course of this investigation, it was learned that R1 was having a difficult day so day program personnel from Central Valley Training Center felt that it would better serve the resident and the day program to have R1 picked up and transported back home to this facility. This decision was made in order to maintain safety at the day program for the other participants and day program staff as well since R1 had a history of physical and verbal aggression coupled with property destruction.
It was learned that S1 was dispatched to go ahead and pick up R1 so that he could be brought back to
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE:

DATE: 09/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2023
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-20230606120748
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: WALTERS RESIDENTIAL HOME CARE 4
FACILITY NUMBER: 392701118
VISIT DATE: 09/27/2023
NARRATIVE
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this facility on 04/25/2023. It was learned that S1 was the only facility staff person who went to pick up R1.
Based on interviews, it was learned that R1 became resistant to S1 when attempting to place R1 into the vehicle of S1. As a result, R1 and S1 fell onto the ground with S1 pinning R1 onto the ground in a form of restraint. It was learned that day program staff had to intervene in order for S1 to lift the restraint and allow R1 to return to an isolated exterior area.
S1 had to finally call the facility and request that another staff person come to the day program in order to deal with R1 and assist in directing R1 into S1's vehicle so that R1 could be removed from the day program and brought home.

As a result of this investigation, this LPA found the allegation to be SUBSTANTIATED - A finding that the complaint was Substantiated meant that the allegation was valid because the preponderance of the evidence standard had been met.

The following deficiencies were observed and cited on the following LIC 9099-D pursuant to Title 22 Rules and Regulations, Division 6 and Health and Safety Codes.

Appeal rights were printed and a copy was left with the facility designated Administrator at this time.

Exit Interview
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE:

DATE: 09/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 5
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
06/06/2023 and conducted by Evaluator Charlie Yang
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20230606120748

FACILITY NAME:WALTERS RESIDENTIAL HOME CARE 4FACILITY NUMBER:
392701118
ADMINISTRATOR:KOAYEN, TANNEHFACILITY TYPE:
735
ADDRESS:4011 OAK VALLEY RDTELEPHONE:
(510) 688-3552
CITY:STOCKTONSTATE: CAZIP CODE:
95205
CAPACITY:4CENSUS: DATE:
09/27/2023
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Tanneh KoayenTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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9
Untrained staff
INVESTIGATION FINDINGS:
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Unannounced complaint visit made out to this facility on 09/27/2023 and this Licensing Program Analyst (LPA) was met by the facility designated Administrator, Tanneh Koayen, who was briefly interviewed at this time.
Current census was 4 residents.
The purpose of this visit was to deliver the findings of this complaint investigation to the facility and it's representatives at this time.
Based on a review of the forms and documents that were gathered during the course of this investigation, it was learned that all facility staff providing care and supervision to the residents received about 40 hours of training every two years. These hours were completed in order to renew and update their MAB, Management in Behavior Training, with certification on file. A review of the forms and documents that were gathered revealed that current M1 MAB Training was completed as recent as 05/17/2022 and valid for 2 years from date of completion.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE:

DATE: 09/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 27-AS-20230606120748
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: WALTERS RESIDENTIAL HOME CARE 4
FACILITY NUMBER: 392701118
VISIT DATE: 09/27/2023
NARRATIVE
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As a result of this investigation, this Department found the allegation to be UNSUBSTANTIATED. A complaint allegation finding of Unsubstantiated meant that although the allegation may have happened or was valid, there was not a preponderance of the evidence to prove that the alleged violation occurred.

There were no deficiencies observed or cited at this time.

Exit Interview
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE:

DATE: 10/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 27-AS-20230606120748
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: WALTERS RESIDENTIAL HOME CARE 4
FACILITY NUMBER: 392701118
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/27/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/04/2023
Section Cited
CCR
80072(a)(3)
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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, or toileting: or withholding of
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The facility representative stated that all facility staff providing care and supervision to the facility residents will undergo follow up training related to detecting potential behavior issues, de-escalation, proper restraints when warranted. A statement of correction, along with proof of training
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shelter, clothing, medication or aids to physical functioning.
This facility was found to be deficient as evidenced by facility personnel physically holding down a resident and performing a single person restraint posing an immediate threat to the Health, Safety, and Personal Rights of the residents in care.
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subjects, list of vendorized trainers, and list of attendees for no less than (5) hours in duration, will be completed and submitted into CCL by the due date.
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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: Charlie Yang
LICENSING EVALUATOR SIGNATURE:

DATE: 09/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5