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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 405800568
Report Date: 07/23/2024
Date Signed: 07/23/2024 02:16:50 PM

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
07/16/2024 and conducted by Evaluator Rachael De Leon
COMPLAINT CONTROL NUMBER: 29-AS-20240716081512
FACILITY NAME:C.A.L.L.-D.T.A.C.FACILITY NUMBER:
405800568
ADMINISTRATOR:REGINA CEASARFACILITY TYPE:
775
ADDRESS:11700 VIEJO CAMINOTELEPHONE:
(805) 466-0766
CITY:ATASCADEROSTATE: CAZIP CODE:
93422
CAPACITY:45CENSUS: 31DATE:
07/23/2024
UNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Ty Leach, Back up to AdministratorTIME COMPLETED:
02:25 PM
ALLEGATION(S):
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Staff did not treat clients with respect
Staff did not assist clients to the restroom
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) De Leon conducted a 10-day complaint visit to the facility above. LPA met with Back up to Administrator Ty Leach. Administrator is out sick today and joined by speaker phone at the begining of the visit. LPA explained the purpose of the visit to Administrator and back up.

LPA De Leon requested the following documentation: Staff Roster with telephone numbers, staff schedule 07/13-07/18, 2024, Names of staff assigned to Park on 07/15/2024, Facility smoking policy, names of Residents assigned to Park on 07/15/2024, Facility cell phone policy, Residents 1, 2, 3 (R1, R2, R3) LIC. 602 Physicians Report and Appraisal Needs and Services Plan or IPP.

Back up to Administrator provided all records and provided additional records of staff 1 (S1) Disciplinary records for incidents on 07/15/2024 and client rights training schedule for July 24, 2024 staff are scheduled to take at 2:00pm.
Continued 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Rachael De Leon
LICENSING EVALUATOR SIGNATURE:

DATE: 07/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/23/2024
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 3
Control Number 29-AS-20240716081512
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.-D.T.A.C.
FACILITY NUMBER: 405800568
VISIT DATE: 07/23/2024
NARRATIVE
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LPA reviewed records on 07/23/2024 at 10:00am. LPA conducted interview with Witness on 07/16/2024 at 4:19pm and on 07/23/2024 with staff around 10:30am.

On the allegation: Staff did not treat clients with respect. LPA reviewed Disciplinary records for Staff 1(S1) had two records for the day of 07/15/2024, one for smoking within 10 feet of clients and one for making an inappropriate statement to Staff 2 (S2) about resident 1 (R1). LPA interviewed witness which revealed seeing S1 smoking near the clients and hearing S1 making an inappropriate statement about R1. Staff interviewed revealed S1 was smoking and did make an inappropriate comment about R1. LPA interviews with staff revealed S2 was talking on cell phone on 07/15/2024, the client ratio that day for staff was 1 staff to 3 clients, S2 was able to use the cell phone at that time remaining within ratio. LPA reviewed San Luis Obispo County Policy on Smoking, smoking in public is prohibited in the City of Atascadero and in 2020 smoking was prohibited at State Parks and Beaches. Based on the evidence this allegation is deemed Substantiated at this time.

On the allegation: Staff did not assist client to the restroom. LPA interviewed Staff which revealed Resident 2 (R2) got out of the van in the parking lot and took off to the restroom at the park, Staff 1 (S1) did not assist R2 to the restroom, S1 did not check the restroom before R2 used the restroom. S2 was assisting Resident 3 (R3) out of the van and to the rest room. Resident 1 (R1) had also went to the restroom and S1 did not assist R1 or check the restroom prior to R1's use. LPA reviewed LIC 602A Physicians reports for R1, R2 and R3, according to the reports R1, R2, and R3 are not able to leave the facility unassisted, so if leaving the facility staff must provide assistance to R1, R2 and R3. R2's Lic. 602 also states R2 needs assistance with caring for toileting needs. According to staff, R3 is to be supervised at all times but R1 and R2 are to be checked on with staff eyes on them every 5 minutes. LPA De Leon reviewed R1, R2, ad R3's Individual Service Plans, according the plan R1 needs verbal prompting for Activities of Daily Living (ADL's) tasks, R2's Individual Service Plan requires level 3 supervision/assistance with hygiene needs, level 3 is defined as requires moderate physical assistance throughout the hygiene process and it is noted R2 will be continuously monitored. R3's service plan also states R3 is a level 3 and requires moderate physical assistance and it is noted R3 will be monitored every 1-2 minutes. Clients are non-verbal and communicate with gestures or actions. Based on the evidence this allegation is Substantiated at this time.

Exit interview conducted, deficiencies cited, copy of report and appeal rights printed for back up Administrator.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Rachael De Leon
LICENSING EVALUATOR SIGNATURE:

DATE: 07/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/23/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 29-AS-20240716081512
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.-D.T.A.C.
FACILITY NUMBER: 405800568
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/23/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/30/2024
Section Cited
CCR
82072(a)(1)
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(a) Each client shall have personal rights which include, but are not limited to, the following:(1) To be accorded dignity in his/her personal relationships with staff and other persons. This requirement was not met as evidenced by:

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Administrator agreed to hold trinaing on personal rights and rights of clients with disabilites, facility policy and procedures for smoking and personal cell phone use. Provide proof of triaing with staff signatures for all staff working or on call at the ADP to CCL.
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Based on interviews and record review the Licensee did not comply with the regulation above, S1 was smoking around R1,R2, & R3 and S1 was talking inappropriate about R1 to S2 which posses a potential personal rights risk to residents in care.
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Type B
07/30/2024
Section Cited
CCR
82078(a)
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(a) The licensee shall provide care and supervision necessary to meet the client's needs and all services specified in the admission agreement. this requirement was not met as evidenced by:
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Administrator agreed to review all clients LIC 602A physicians reports, IPP's and behavior plans and provide the required care and supervision to those clients based on their needs, Train all staff on each clients needs and services and provide proof of training with all staff signatures to CCL.
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Based on interview and record review the Licensee did not comply with the regulation above, S1 did not provide supervision with R1 and R2 in the public restroom which poses a potential health and safety 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: Kelly Burley
LICENSING EVALUATOR NAME: Rachael De Leon
LICENSING EVALUATOR SIGNATURE:

DATE: 07/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/23/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3