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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 397000569
Report Date: 04/05/2024
Date Signed: 05/03/2024 11:34:06 AM

Substantiated


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
02/15/2024 and conducted by Evaluator Kesha Lewis
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20240215091759
FACILITY NAME:WILLOW CARE HOMEFACILITY NUMBER:
397000569
ADMINISTRATOR:QUIAOT, KATHLEENFACILITY TYPE:
735
ADDRESS:1633 WILLOW PARK WAYTELEPHONE:
(209) 462-2923
CITY:STOCKTONSTATE: CAZIP CODE:
95206
CAPACITY:6CENSUS: 3DATE:
04/05/2024
UNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:QUIAOT, KATHLEENTIME COMPLETED:
11:30 AM
ALLEGATION(S):
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Neglect/lack of care and supervision
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 licensee joined about 20 minutes later LPA explained the reason for the visit.

Based on the interviews and statements obtained during the investigation process, the allegations are determined to be substantiated. The Department conducted interviews with three staff members and residents. Admin, S1, S2 and collaborating agency representatives(See confidential name list LIC-811 dated 5/03/2024) all provided statements to the department that confirm that R2 had a history of bringing potentially dangerous objects into the facility upon returning from community outings. Based on records reviewed the facility failed to create a plan to prevent R2 from bringing items into the facility that could be dangerous. R1 was stuck with a crowbar by R2. S1, S2, R1, R2 and the Administrator confirm that the incident occurred. At the time of the incident one staff was present.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Kesha Lewis
LICENSING EVALUATOR SIGNATURE:

DATE: 04/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2024
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 3
Control Number 27-AS-20240215091759
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: WILLOW CARE HOME
FACILITY NUMBER: 397000569
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/05/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/22/2024
Section Cited
CCR
85078(a)(1)
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NEGLECT & LACK OF SUPERVISION -(a) In addition to Section 80078, the following shall apply: (a)(1) The licensee shall provide those services identified in the client's needs and services plan as necessary to meet the client's needs.This requirement was not met as evidenced by:
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 Licensee will conduct training for staff on intervention of behaviors and implements residents IPP'S. The plan will be sent to licensing by COB 5/6/2024.
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Based on records reviewed the facility failed to create a plan to prevent R2 from bringing items into the facility that could be dangerous.
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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: 08/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 27-AS-20240215091759
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: WILLOW CARE HOME
FACILITY NUMBER: 397000569
VISIT DATE: 04/05/2024
NARRATIVE
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The above allegation is SUBSTANTIATED A finding that the complaint allegation is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. This poses an immediate health, safety, and personal rights risk to residents in care.

Deficiencies are being cited from the California Code of Regulations (CCR) Title 22, Division 6. A civil penalty is also being assessed. This incident is currently under review and a future civil penalty may apply based on 1569.49(f) H&S. Failure to correct the deficiencies may also result in civil penalties. Exit interview conducted. A copy of this report and appeal rights were provided.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Kesha Lewis
LICENSING EVALUATOR SIGNATURE:

DATE: 04/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3