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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 397002220
Report Date: 08/25/2023
Date Signed: 08/25/2023 11:46:00 AM

Unsubstantiated


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
07/21/2023 and conducted by Evaluator Maja Jensen
COMPLAINT CONTROL NUMBER: 27-AS-20230721091517
FACILITY NAME:PERSON CENTERED SERVICES, INC #2FACILITY NUMBER:
397002220
ADMINISTRATOR:ANN MARRIOTTFACILITY TYPE:
775
ADDRESS:4155 N. EL DORADO STREETTELEPHONE:
(209) 466-2448
CITY:STOCKTONSTATE: CAZIP CODE:
95207
CAPACITY:135CENSUS: 73DATE:
08/25/2023
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Shelly BrayTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Staff did not prevent inappropriate sexual interaction between clients
INVESTIGATION FINDINGS:
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On 8/25/23 at approximately 10am Licensing Program Analyst Maja Jensen arrived at facility unannounced to continue a complaint investigation in to the above listed allegation. LPA Jensen met with Program Director Shelly Bray and explained the purpose of the visit.

On 7/7/23 client 1 (C1) made a report to day program staff approximately 30 minutes before program was over that client 2 (C2) had inappropriately touched her. At this time C1 stated that she did not want to go in to the office to discuss it any further and left for the day. Staff notified the Program Director what was said by C1. Upon returning to program on 7/10/23, C1 again reported that C2 had touched her inappropriately. In an effort to support C1, facility staff asked how they can assist and how would she like to handle this situation. C1 advised she would like assistance in talking to C2. A meeting was held with C1 and C2 as well as staff 1 (S1) and staff 2 (S2). C2 denied the allegations and both C1 and C2 agreed to give each other space.
Continued on LIC 9099C...
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE:

DATE: 08/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2023
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 4
Control Number 27-AS-20230721091517
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: PERSON CENTERED SERVICES, INC #2
FACILITY NUMBER: 397002220
VISIT DATE: 08/25/2023
NARRATIVE
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LPA Jensen conducted interviews with S1, S2 and C1. LPA Jensen also interviewed the Licensee of the home where C1 resides.

LPA Jensen reviewed records that include the resident files for C1 and C2 as well as day program staff notes regarding the incident in question.

Based on the records reviewed and the interviews conducted, C1's account of the events that occurred has been inconsistent. In addition, C1 is noted as having a history of making false allegations. C1 has consistently expressed that she feels safe at Day Program and has repeatedly requested staff not report this allegation to law enforcement or any other entity. Based on the C1's inconsistent recollection of events, a lack of witnesses and C1's history of behaviors, the allegation of staff did not prevent inappropriate sexual interaction between clients is UNSUBSTANTIATED. A finding of UNSUBSTANTIATED means that although the allegation may have happened, the preponderance of evidence does not prove it.

An exit interview was conducted and a copy of this report, an LIC 811 and appeal rights were provided.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE:

DATE: 08/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 4
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
07/21/2023 and conducted by Evaluator Maja Jensen
COMPLAINT CONTROL NUMBER: 27-AS-20230721091517

FACILITY NAME:PERSON CENTERED SERVICES, INC #2FACILITY NUMBER:
397002220
ADMINISTRATOR:ANN MARRIOTTFACILITY TYPE:
775
ADDRESS:4155 N. EL DORADO STREETTELEPHONE:
(209) 466-2448
CITY:STOCKTONSTATE: CAZIP CODE:
95207
CAPACITY:135CENSUS: 73DATE:
08/25/2023
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Shelly BrayTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Staff did not properly report an incident involving a client
INVESTIGATION FINDINGS:
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On 8/25/23 at approximately 10am Licensing Program Analyst Maja Jensen arrived at facility unannounced to continue a complaint investigation in to the above listed allegation. LPA Jensen met with Program Director Shelly Bray and explained the purpose of the visit.

On 7/7/23 and again on 7/10/23 a day program client (C1) reported that she was touched inappropriately by another client. The facility conducted an investigation and concluded that the allegation lacked credibility. C1 requested that the allegation not be reported to any other entities and that the issue be dropped. The facility did not report the incident within the required time frame and as a result deficiencies are being cited from California Code of Regulations (CCR) Title 22, Division 6. Failure to correct deficiencies may result in the assessment of civil penalties.

An exit interview was conducted and a copy of this report and appeal rights were provided.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE:

DATE: 08/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2023
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 4
Control Number 27-AS-20230721091517
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: PERSON CENTERED SERVICES, INC #2
FACILITY NUMBER: 397002220
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/25/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/25/2023
Section Cited
CCR
82061(a)(1)(D)
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Reporting Requirements
Upon the occurrence, during the hours the day program is providing services to the client, of any of the events specified in Section 82061(a)(1), a report shall be made to the licensing agency within the agency's next working day during its normal business hours. In addition, a written report ...shall be submitted to the licensing agency within seven days following the occurrence of the event. This requirement was not met as evidenced by:
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The Licensee agrees to complete in-service mandated reporter training with staff and will email proof of completion to maja.jensen@dss.ca.gov by the POC due date.
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A client reported being touched inappropriately by another client in July and conducted an internal investigation however did not report the incident to the Department. This poses a potential threat to the health, safety and personal rights of clients in care.
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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: 08/25/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 4