405800333-10-31-2023-29-AS-KBUY-CZYM6M-20240130082006

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 405800333
Report Date: 10/31/2023
Date Signed: 10/31/2023 09:56:39 AM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/20/2023 and conducted by Evaluator Mark Jeffries

COMPLAINT CONTROL NUMBER: 29-AS-20230120154937

FACILITY NAME:	C.A.L.L.-PALOMAR HOUSE		FACILITY NUMBER:	405800333
ADMINISTRATOR:	REGINA R. CEASAR		FACILITY TYPE:	735
ADDRESS:	8902 PALOMAR		TELEPHONE:	(805) 462-2421
CITY:	ATASCADERO	STATE: CA	ZIP CODE:	93422
CAPACITY:	6	CENSUS: 5	DATE:	10/31/2023
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Administrator Randyn Torres		TIME COMPLETED:	11:05 AM

ALLEGATION(S):

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Lack of supervision resulting in resident consuming chemicals.
Staff did not provide timely medical assistance.

INVESTIGATION FINDINGS:

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On 10/31/2023 at 9:00amam, Licensing Program Analyst (LPA) Mark Jeffries conducted an unannounced follow-up visit to deliver final findings on the original complaint dated 1/25/2023. LPA met with Administrator Randyn Torres, and explained the purpose of the visit.

On the allegation, “Lack of supervision resulting in resident consuming chemicals,” the complainant’s concern was that a client consumed Pine-sol cleaner at the facility. The Administrator stated on 1/12/2023 around 8:30pm they received a call from a staff, who stated they stopped Client 1 (C1) from taking the bottle that was on their mouth, and was not sure if the client consumed any. The staff called Poison Control and the Administrator. According to the incident report, Poison Control stated the client would be fine, and that Pine-Sol Multi Surface Cleaner is just a heavier soap. Poison Control stated if the client consumed mild soap, watch for vomiting and/or diarrhea and give the client lots of fluids. Another staff wrote up an incident report. Two other staff observed the client’s condition.
CONTINUED on LIC9099-C

Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Mark Jeffries
LICENSING EVALUATOR SIGNATURE:	DATE: 10/31/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20230120154937

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: C.A.L.L.-PALOMAR HOUSE	FACILITY NUMBER: 405800333
	VISIT DATE: 10/31/2023

NARRATIVE

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The Pine-sol was on the counter in the kitchen, to the left of the kitchen sink and they were not sure who left it on the counter. However, a staff was in the process of mopping the floor. The Administrator was off on the weekend and contacted C1’s family member to notify them on 1/15/2023. C1 did not exhibit symptoms of vomiting and diarrhea, and resumed normal activities. The staff left the Pine-sol unattended on the counter, which put clients at risk and allowed C1 to consume chemicals. Based on the information obtained, the allegation “Lack of supervision resulting in resident consuming chemicals” is deemed Substantiated at this time.

On the allegation, “Staff did not provide timely medical assistance,” the complainant’s concern was that Client 2 (C2) was not getting timely medical care. The Administrator stated on 1/13/2023 at approximately 7pm, C2 was admitted to the hospital. On 1/12/2023 staff noticed C2, who is nonverbal, moaning more and shivering and shaking, appearing uncomfortable. C2 was provided Tylenol and they were ok, but the next evening the behaviors became more extreme and was stiff and shaking. Staff called another staff at 5:45pm, and C2 was taken to the hospital. LPA reviewed client charting for the week before the hospitalization. On 1/8/2023 and 1/9/2023, the charting indicates C2 slept fine and there were no issues. On 1/10/2023, it indicates C2 had a rough night and was shaking, and was not listening to staff. On 1/11/2023, C2 was shaking when being woken up for the bathroom but had a good night and slept well otherwise. On 1/12/2023, notes state C2 was screaming and had a bad night, and it seemed like C2 was in a lot of pain. C2 was provided a PRN. On 1/13/2023 in the morning, C2 was shaking and provided C2 a PRN for pain. Notes indicate C2 had a “bad day” and went to the hospital due to yelling in pain. Hospital records indicate C2 was diagnosed with Rhabdomyolysis, seizures, hyponatremia, COVID, and leg pain/swelling. The staff were aware C2 started shaking on 1/10/2023 and experienced a change in behavior, and on the night of 1/12/2023 C2 was screaming and staff thought C2 was in pain. However, staff did not seek medical attention for C2 until the evening of 1/13/2023. C2 was discharged on 1/23/2023 after spending 10 days in the hospital. Based on the information obtained, the allegation, “Staff did not provide timely medical assistance” is deemed Substantiated at this time.

Exit interview, deficiencies cited on 9099-D, report given, appeal rights given.

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Mark Jeffries
LICENSING EVALUATOR SIGNATURE:	DATE: 10/31/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2023

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20230120154937

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: C.A.L.L.-PALOMAR HOUSE	FACILITY NUMBER: 405800333
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/31/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 11/01/2023 Section Cited CCR 80087(a)	1 2 3 4 5 6 7	80087(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. As evidence of C1 ingesting chemicals that were left out, which puts clients at imitate danger..	1 2 3 4 5 6 7	Administrator agrees to conduct 1 hour of general safety including storage and locking of chemical .
Type A 11/01/2023 Section Cited CCR 80075(a)	1 2 3 4 5 6 7	80075(a) The licensee shall ensure that each client receives necessary first aid and other needed medical or dental services, including arrangement for and/or provision of transportation to the nearest available services. This	1 2 3 4 5 6 7	Administrator agrees to conduct 1 hour of general safety including storage and locking of chemical .
	8 9 10 11 12 13 14	requirement was not met by evidence of C2 delayed in seeking medical attention in a timely manor. Which puts clients in imitate danger..	8 9 10 11 12 13 14
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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: Kelly Burley
LICENSING EVALUATOR NAME: Mark Jeffries
LICENSING EVALUATOR SIGNATURE:	DATE: 10/31/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2023

LIC9099 (FAS) - (06/04)

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