405800728-9-8-2022-29-AS-KBUY-CJ4RME-20220909130838

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 405800728
Report Date: 09/08/2022
Date Signed: 09/08/2022 08:15:12 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
08/31/2022 and conducted by Evaluator Mark Jeffries

COMPLAINT CONTROL NUMBER: 29-AS-20220831143524

FACILITY NAME:	DERRICK FAMILY HOME		FACILITY NUMBER:	405800728
ADMINISTRATOR:	DONNA DERRICK		FACILITY TYPE:	735
ADDRESS:	9395 HUER HUERO ROAD		TELEPHONE:	(805) 438-4513
CITY:	CRESTON	STATE: CA	ZIP CODE:	93432
CAPACITY:	2	CENSUS: 2	DATE:	09/08/2022
		UNANNOUNCED	TIME BEGAN:	08:00 AM
MET WITH:	Robert Derrick/Licensee		TIME COMPLETED:	10:00 AM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Client is required to chop wood
Client is left unsupervised

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

At 8:00am on 09/08/2022, Licensing Program Analyst (LPA) Jeffries arrived at the facility to conduct and unannounced investigation to the allegations of this complaint. LPA met with Licensee Rob Derrick (S1) and announced the reason for the visit. LPA interviewed Licensee, Staff, both clients (C1 and C2), requested and reviewed documentation. LPA was able to issue the following final findings based on the following:
As to the allegation of, “Client is required to chop wood.” It was discovered through interviews and review of past complaint (29-AS-20220316101459) that C1 is not forced or required to chop wood. In an interview at 8:30am on 09/08/2022, C1 stated that they feel good when they chop wood and if they didn’t want to chop wood they would not. C1 stated that C1 has 4 to 5 year experience in chopping wood and S1 or S2 are always near when C1 is chopping wood. In interview with S1 discovered that C1 likes to help chop wood and would not require C1 to chop wood if C1 didn’t want to chop wood. Prior complaint reflects similar interview findings. Interview of C2 revealed that they are not requiored or forced to do anything they dont want to do. LPA noted that C1 has lived at this facility for 33 years and C2 has lived at this facility for 32 years.
CONTINUED on LIC9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Mark Jeffries
LICENSING EVALUATOR SIGNATURE:	DATE: 09/08/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2022

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-20220831143524

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: 09/08/2022

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Based on interviews and prior complaint findings, the allegation of “Client is required to chip wood.” is unsubstantiated at this time.
As to the allegation of, “Client is left unsupervised.” It was discovered through LPA reviewing C1’s physician’s report dated 03/30/2021 and Individual Program Plan (IPP) dated 01/25/2022. Physician’s report and IPP indicate C1 is very high functioning and does not need constant supervision. C1 and S1 stated they feel comfortable chopping wood and handling tools safely without constant supervision. In interview, S1 stated someone is always on site when C1 is present and chopping wood. S1 stated C1 knows how to properly use tools to safely chop the wood without supervision. Interview with C1 indicated a high functioning person. Based on the interviews and documentation the allegation of "Client is left unsupervised." is unsubstantiated at this time.

Exit interview, report signed, and report emailed.

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Mark Jeffries
LICENSING EVALUATOR SIGNATURE:	DATE: 09/08/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 2