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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 397005617
Report Date: 02/07/2022
Date Signed: 02/07/2022 02:50:42 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
01/07/2022 and conducted by Evaluator Albert Johnson
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20220107084811
FACILITY NAME:WALTERS RESIDENTIAL HOME CAREFACILITY NUMBER:
397005617
ADMINISTRATOR:MOSES WALTERS SR.FACILITY TYPE:
735
ADDRESS:2746 ABRUZZI COURTTELEPHONE:
(510) 688-3552
CITY:STOCKTONSTATE: CAZIP CODE:
95206
CAPACITY:6CENSUS: 6DATE:
02/07/2022
UNANNOUNCEDTIME BEGAN:
01:31 PM
MET WITH:J. BurgessTIME COMPLETED:
03:02 PM
ALLEGATION(S):
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Staff pushed resident while in care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Albert Johnson made contact with Staff J. Burgess to deliver findings.

Based on records reviewed and interviews conducted with staff and residents it was discovered that on 24th of December 2021, R1 was upset about no being able to go on an outing to a fast food resturant. R1 called the police, the police arrived and interviewed all parties. The responding Officers did not write or leave a report number or incident card. The reponding Officers are aware of R1 behaviors and R1 given a verbal warning about calling for things like being upset about not being able to go an outing or for getting into an argument with a housemate or witnessing an argument between two other housemates. In other words, non-emergency situations.

Continued
Unsubstantiated
Estimated Days of Completion: 0
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE:

DATE: 02/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/07/2022
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-20220107084811
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: 02/07/2022
NARRATIVE
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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 pushed 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: 02/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/07/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2