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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 405800728
Report Date: 03/16/2022
Date Signed: 03/16/2022 12:12:44 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, 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
03/16/2022 and conducted by Evaluator Jeannette Olson
COMPLAINT CONTROL NUMBER: 29-AS-20220316101459
FACILITY NAME:DERRICK FAMILY HOMEFACILITY NUMBER:
405800728
ADMINISTRATOR:DONNA DERRICKFACILITY TYPE:
735
ADDRESS:9395 HUER HUERO ROADTELEPHONE:
(805) 438-4513
CITY:CRESTONSTATE: CAZIP CODE:
93432
CAPACITY:2CENSUS: 2DATE:
03/16/2022
UNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Donna Derrick, LicenseeTIME COMPLETED:
10:25 AM
ALLEGATION(S):
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Client is required to chop wood for a long period of time.
Client is left unsupervised.
Staff yells at client.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Olson conducted an unannounced initial complaint visit. LPA was accompanied by Tri-Counties Regional Center Quality Assurance Specialist (QAS) Jeff Edler. LPA met with Licensee, Donna Derrick and explained the purpose of the visit.

LPA and QAS interviewed one client and Licensee from (9:10 am to 9:40am), LPA reviewed documents at 9:45am. LPA and QAS talked to Staff Rob Derrick over the phone at 9:50 AM.

On the allegation: Client is required to chop wood for a long period of time. During interviews, client expressed no issues with chopping wood, they stated they love to chop wood and no one forces them to chop it. Client 1 is very high functioning and loves working and helping Staff work. Client 1 stated they can stop chopping whenever they want to and can take breaks when wanted.
Continued on 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Jeannette Olson
LICENSING EVALUATOR SIGNATURE:

DATE: 03/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/16/2022
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 29-AS-20220316101459
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: DERRICK FAMILY HOME
FACILITY NUMBER: 405800728
VISIT DATE: 03/16/2022
NARRATIVE
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Client 1 stated they have an awning when its sunny. Staff interviews revealed Client 1 enjoys chopping wood and staff do not pressure or require them to chop more than the client wants. Based on the information obtained, the allegation is Unsubstantiated.

On the allegation: Client is left unsupervised. LPA reviewed Client 1’s physician’s report and Individual Program Plan (IPP). Physician’s report and IPP indicate Client 1 is very high functioning and does not need constant supervision. Client 1 and Staff stated they feel comfortable chopping wood and handling tools safely without constant supervision. Staff interviewed stated someone is always on site when Client 1 is present and chopping wood and are within earshot if Client 1 needs anything. Staff stated Client 1 knows how to properly use tools to safely chop the wood without supervision. Based on the information obtained, the allegation is Unsubstantiated.

On the allegation: Staff yells at Client. Interviews with Client revealed they enjoy living at the facility and like the staff. Client stated they are never yelled at by staff. Staff interviewed stated they do not yell at the clients. Staff stated they talk loudly sometimes and will increase their voice to be heard across the noise of the tractor or wood splitter to property to communicate with Client 1. Based on the information obtained, the allegation is Unsubstantiated.

Exit interview, report given.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Jeannette Olson
LICENSING EVALUATOR SIGNATURE:

DATE: 03/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/16/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2