405801348-10-11-2022-29-AS-KBUY-CK5VP2-20221012163602

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 405801348
Report Date: 10/11/2022
Date Signed: 10/11/2022 03:38:49 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
09/14/2022 and conducted by Evaluator Darlene Chavez

COMPLAINT CONTROL NUMBER: 29-AS-20220914084459

FACILITY NAME:	KEEFE'S KOTTAGE		FACILITY NUMBER:	405801348
ADMINISTRATOR:	DAVID KEEFE		FACILITY TYPE:	735
ADDRESS:	10320 EL CAMINO REAL		TELEPHONE:	(805) 466-1247
CITY:	ATASCADERO	STATE: CA	ZIP CODE:	93422
CAPACITY:	6	CENSUS: 5	DATE:	10/11/2022
		UNANNOUNCED	TIME BEGAN:	03:23 PM
MET WITH:	David Keefe, Licensee/Administrator		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Resident was physically assaulted while in care.
Resident was forced to drink alcohol while in care
Resident sustained an injury while in care

INVESTIGATION FINDINGS:

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On 10/11/22 at 3:20 pm, Licensing Program Analyst (LPA) Darlene Chavez conducted an unannounced follow-up complaint investigation visit to the facility above to deliver final findings. LPA met with David Keefe, Licensee/Administrator, and explained the purpose of the visit.

On the allegation, “Resident was physically assaulted while in care,” the complainant’s concern was that Resident #1 (R1) had been “tied to a chair, beat with a bat and had alcohol shoved down their throat” at the facility. To investigate, LPA interviewed the licensee, staff, and residents and reviewed records.

On 9/15/22 between 10:00 am and 10:30 am, LPA interviewed staff. Staff state that they observed R1 acting differently and that R1 appeared to have been drinking alcohol. Staff say they did not cause harm nor injury to R1 and that in fact, they were concerned about R1 and kept checking on resident. Licensee states that, after R1 had gone to the bathroom to shower, licensee noticed R1 had a cut on their forehead above the eye. Licensee asked R1 if they were okay, and R1 replied, “no, I’m okay.” Licensee asked R1 how they got the cut, and R1 did not say how they got the injury. Continued on 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Darlene Chavez
LICENSING EVALUATOR SIGNATURE:	DATE: 10/11/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2022

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 3

Control Number 29-AS-20220914084459

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: KEEFE'S KOTTAGE	FACILITY NUMBER: 405801348
	VISIT DATE: 10/11/2022

NARRATIVE

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On 9/15/22 between 11:18 am and 11:23 am, LPA interviewed residents. Residents say they did not observe cuts or injury to R1. They say they did not hear any noises that were loud or unusual.

On 10/8/22, LPA reviewed Atascadero Police Department’s Incident Report regarding the alleged event. In the report, an officer interviewed R1, toured the facility, and looked in R1’s room. The officer reports that they “did not see any obvious signs of struggle or assault.” The officer reports there was a small amount of blood in the bathroom, however, the final findings were, “I did not find sufficient evidence to suspect a crime occurred.”

Based in evidence obtained, the allegation, “Resident was physically assaulted while in care,” is deemed Unsubstantiated at this time. Interviews reveal that R1’s injury was inflicted during an accident in the shower, and not inflicted by staff.

On the allegation, “Resident was forced to drink alcohol while in care,” the complainant was concerned that R1 “had alcohol shoved down R1’s throat at the group home, Keefe's Kottage.” LPA investigated by interviewing the licensee, staff, and residents.

On 9/15/22 between 10:00 am and 10:30 am, LPA interviewed staff. Staff report that R1 was slurring their words, giggling, and inebriated. Staff say they found a bottle of alcohol in R1’s room and they were not the ones who provided the alcohol to R1.

On 9/15/22 at 1:43 pm, LPA interviewed R1. R1 admits that they purchased alcohol from the store and says that staff did not force R1 to drink it. On 10/8/22 at 3:34 pm, LPA spoke with R1 again. R1 says they don’t remember anything that happened that day, except wanting to leave the facility.

Based on evidence obtained, the allegation, “Resident was forced to drink alcohol while in care,” is deemed Unsubstantiated at this time. Interviews with R1 suggest conflicting information and interviews with staff show that R1 was not given the alcohol by staff.

On the allegation, “Resident sustained an injury while in care,” the complainant was concerned that R1 sustained an injury due to staff abuse. To investigate the allegation, LPA interviewed the licensee, staff, and resident and reviewed records.

On 9/15/22 between 10:00 am and 10:30 am, LPA interviewed staff. Staff say they did not observe an injury on the resident and did not injure R1. Licensee described that he was standing at R1’s bedroom door and noticed an “injury on the right brow” of R1. Licensee says he asked R1 if they were okay, and R1 replied “no, I’m okay.” Continued on 9099-C.

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Darlene Chavez
LICENSING EVALUATOR SIGNATURE:	DATE: 10/11/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 29-AS-20220914084459

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: KEEFE'S KOTTAGE	FACILITY NUMBER: 405801348
	VISIT DATE: 10/11/2022

NARRATIVE

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On 9/15/22 at 1:43 pm, LPA interviewed R1. R1 states that they, “slipped and fell in the shower and hit my forehead above my eye brow and I got a cut.” R1 says staff did not cause harm or injury to R1.

On 10/8/22, LPA reviewed R1’s hospital records. Hospital records from a visit on 8/31/22 indicate R1 was seen for “a laceration above right eye.” The report’s conclusion reads, “1. No evidence of acute intracranial injury. 2. Mild atrophy.”

Based on the evidence obtained, the allegation “Resident sustained an injury while in care,” is deemed Unsubstantiated at this time. Interviews conclude that R1 had an injury caused by an accident, and staff did not cause the injury to R1.

Exit interview conducted and the report emailed to Licensee.

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Darlene Chavez
LICENSING EVALUATOR SIGNATURE:	DATE: 10/11/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2022

LIC9099 (FAS) - (06/04)

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