397005617-9-8-2021-27-AS-KHOS-C6VNKC-20210915103145

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 397005617
Report Date: 09/02/2021
Date Signed: 09/08/2021 02:24:49 PM

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
08/04/2021 and conducted by Evaluator Albert Johnson

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20210804141457

FACILITY NAME:	WALTERS RESIDENTIAL HOME CARE		FACILITY NUMBER:	397005617
ADMINISTRATOR:	MOSES WALTERS SR.		FACILITY TYPE:	735
ADDRESS:	2746 ABRUZZI COURT		TELEPHONE:	(510) 688-3552
CITY:	STOCKTON	STATE: CA	ZIP CODE:	95206
CAPACITY:	6	CENSUS: 4	DATE:	09/02/2021
		UNANNOUNCED	TIME BEGAN:	01:16 PM
MET WITH:	Tanneh Koayen		TIME COMPLETED:	03:15 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility staff caused injury to resident
Facility staff hit resident

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Albert Johnson made contact with Tanneh Koayen, Administrator to deliver findings.

Based on records reviewed and interviews conducted with staff and residents it was discovered that on Wednesday the 4th of August 2021, R1 got into a fight with another consumer because he said the consumer refused to speak to him upon his return from the Day Program. He scraped his knee in the process. Staff parted them, calmed and redirected him.

On the Friday, the 6th of August 2021, R1 had an outburst, started screaming outside of the facility in the neighborhood.
Continued

Unsubstantiated

Estimated Days of Completion: 0

SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE:	DATE: 09/02/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/02/2021

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-20210804141457

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: WALTERS RESIDENTIAL HOME CARE	FACILITY NUMBER: 397005617
	VISIT DATE: 09/02/2021

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

On the Friday, the 6th of August 2021, R1 had an outburst, started screaming outside of the facility in the neighborhood. The neighbors called the police on him. He was subsequently warned by the police for his public disturbance. On, Monday the 9th of August, R1 called the police for nothing when he returned from the Day Program. The police advised him to talk to staff the next time he has any issue.

The IPP for R1 includes information about R1 making false statement and allegations against family members and staff, it was also noted that R1 has a history of being aggressive with other’s (staff and peers) by hitting and pushing them. He also punches holes in the walls, goes outside yelling and screaming until the neighbors call the police per IPP. He requires a lot of attention from staff and will act out until he gets it.

All parties interviewed denied witnessing R1 being hit or mistreated by staff.

The Department (CCLD) has found the allegations. Unsubstantiated.

A finding that the complaint allegation(s) are UNSUBSTANTIATED means that although the allegation(s) may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation(s) occurred.

SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE:	DATE: 09/02/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/02/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 2