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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 405800728
Report Date: 06/27/2023
Date Signed: 06/27/2023 11:23:15 AM

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
06/22/2023 and conducted by Evaluator Jeannette Olson
COMPLAINT CONTROL NUMBER: 29-AS-20230622121910
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:
06/27/2023
UNANNOUNCEDTIME BEGAN:
10:05 AM
MET WITH:Donna Derrick, Administrator/LicenseeTIME COMPLETED:
11:40 AM
ALLEGATION(S):
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Staff are not adequately supervising clients while in care.
Staff use inappropriate language toward clients while in care.
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 Licensee and Client (over the phone). LPA reviewed documents at 11:00am.

On the allegation: Staff are not adequately supervising clients while in care. It was alleged that Client 1 (C1) and Client 2 (C2) are observed to be using a wood splitter without proper supervision. Interviews revealed Client 1 stated they can stop chopping whenever they want to and can take breaks when they want and are always supervised. Client 2 previously expressed no issues with chopping wood, they stated they love to chop wood and no one forces them to chop it. Client 2 was at work and not able to be interviewed today.

Continued on 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Jeannette Olson
LICENSING EVALUATOR SIGNATURE:

DATE: 06/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/27/2023
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-20230622121910
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: 06/27/2023
NARRATIVE
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LPA reviewed Clients physician’s report and Individual Program Plan (IPP). Physician’s report and IPP indicate Client 2 is very high functioning and does not need constant supervision. Clients and Staff stated they feel comfortable chopping wood and handling tools safely without constant supervision. Staff interviewed stated someone is always on site when Clients are chopping wood and are within earshot if Clients need anything. Staff stated Clients know 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 use inappropriate language toward clients while in care. It was alleged that Staff 1 (S1) yells cuss words at clients while they chop wood. Client interviewed stated they are never yelled at or hear cussing from staff. Licensee interviewed stated they do not yell at the clients and S1 does not usually use that type language. Licensee stated (S1) talks loudly sometimes and will increase their voice to be heard across the noise of the tractor or wood splitter to property to communicate with Clients. Based on the information obtained, the allegation is Unsubstantiated.

Exit interview conducted, copy of report issued.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Jeannette Olson
LICENSING EVALUATOR SIGNATURE:

DATE: 06/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/27/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2