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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 392701118
Report Date: 05/24/2024
Date Signed: 05/24/2024 12:50:13 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/09/2024 and conducted by Evaluator Michael Bilger
COMPLAINT CONTROL NUMBER: 27-AS-20240409093200
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:
05/24/2024
UNANNOUNCEDTIME BEGAN:
12:07 PM
MET WITH:Tanneh KoayenTIME COMPLETED:
01:00 PM
ALLEGATION(S):
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Facility staff did not prevent resident for hitting another resident resulting in bruises.
INVESTIGATION FINDINGS:
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On 5-24-24 at 12:07pm, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to deliver and discuss complaint findings for the allegation noted above. LPA met with Administrator Tanneh Koayen and explained the purpose of the visit. During this investigation, LPA conducted interviews with three staff members and two residents in care. LPA also reviewed incident report dated 4-8-24, behavior tracking form for resident1 (R1), behavior intervention plan for R1, and individualized program plan (IPP) for R1 and R2. Based on record reviews and interviews, on 4-7-24, R1 and R2 were engaged in a physical altercation which resulted in R1 running into a garbage can placed in the kitchen, injuring self, and causing bruises. Record reviews also revealed R1 hit R2 which led to R1 running away and into the garbage can. No injuries were caused to R2 according to record reviews and interviews. Additional interviews and record reviews revealed that R1 has a history of behaviors which include striking out at staff and residents.

{Cont. on 9099C}
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE:

DATE: 05/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2024
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 2
Control Number 27-AS-20240409093200
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: WALTERS RESIDENTIAL HOME CARE 4
FACILITY NUMBER: 392701118
VISIT DATE: 05/24/2024
NARRATIVE
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Records further revealed interventions are in place to specifically address these behaviors. The investigation determined that on 4-7-24, R1 and R2 were the only two residents in the facility and staff3 (S3) was on duty. Training records revealed S3 has received appropriate staff training as required. Additionally, it was revealed through interviews that S3 was in line of sight of both residents and providing supervision prior to the event. After the event occurred, both R1 and R2 were immediately separated, Administrator was notified, and incident was reported to Licensing department and regional center.

As a result of this investigation, there is not a preponderance of evidence to prove facility staff did not attempt or have measures in place to prevent resident from hitting another resident. As a result, this allegation is UNSUBSTANTIATED. An allegation of unsubstantiated means the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred.

An exit interview was conducted with Tanneh Koayen and a copy of this report was provided to Tanneh. Appeal rights provided. LIC 811 provided.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE:

DATE: 05/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2