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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 397005738
Report Date: 10/11/2024
Date Signed: 10/11/2024 02:05:28 PM

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
08/23/2024 and conducted by Evaluator Michael Bilger
COMPLAINT CONTROL NUMBER: 27-AS-20240823100640
FACILITY NAME:INSPIRING CAREFACILITY NUMBER:
397005738
ADMINISTRATOR:WILLIAM PUCKETTFACILITY TYPE:
735
ADDRESS:2488 NATHANIEL STREETTELEPHONE:
(209) 951-2405
CITY:STOCKTONSTATE: CAZIP CODE:
95210
CAPACITY:5CENSUS: 0DATE:
10/11/2024
UNANNOUNCEDTIME BEGAN:
12:20 PM
MET WITH:William PuckettTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Staff pushed client
INVESTIGATION FINDINGS:
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On 10-11-24 at 12:20pm, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to deliver findings for the allegation noted above. LPA met with Administrator William Puckett and explained the purpose of the visit. During this investigation, LPA conducted interviews with two staff and an additional eyewitness. LPA also reviewed additional documentation including a restraining order dated 4-5-24, and a written declaration received from witness. Based on interviews and record reviews, it was revealed that resident1 (R1) was receiving supervision from staff3 (S3) on 4-5-24 and pushed by S3 during an attempt to redirect behavior. Interviews and record reviews revealed specifically, that R1 was attempting to walk forward when S3 placed hands on R1’s shoulders and pushed S3 with force strong enough to cause S3 to stumble backwards. No known injuries to R1 resulted from this event. Incident was reported to local law enforcement who issued a temporary restraining order to S3 due to the occurrence as noted above.
As a result, the preponderance of evidence standard is met, and this allegation is SUBSTANTIATED. Citation is issued under Title 22, Division 6 and noted on LIC 9099D. An exit interview was conducted with Administrator and a copy of this report was provided to Administrator. Appeal rights provided.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE:

DATE: 10/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2024
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-20240823100640
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: INSPIRING CARE
FACILITY NUMBER: 397005738
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/11/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/14/2024
Section Cited
CCR
80072(a)(3)
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80072(a)(3). Personal Rights. (a)...each client shall have personal rights which include…(3) To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse, or other actions of a punitive nature…This requirement was not met as evidenced by:
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Licensee to conduct staff training on personal rights and proper forms of redirection. Training date to be submitted to LPA by POC due date with proof of completed training to be submitted to LPA by 10-25-24.
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Based on interview and record review, S3 pushed R1 with force in an attempt to redirect. This posed an immediate health, safety, and resident rights risk to residents 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: Michael Bilger
LICENSING EVALUATOR SIGNATURE:

DATE: 10/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2024
LIC9099 (FAS) - (06/04)
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