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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 405802297
Report Date: 05/25/2023
Date Signed: 05/25/2023 09:57:28 AM

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
05/15/2023 and conducted by Evaluator Darlene Chavez
COMPLAINT CONTROL NUMBER: 29-AS-20230515163632
FACILITY NAME:OPTIONS - LEGATO HOMEFACILITY NUMBER:
405802297
ADMINISTRATOR:DEBRA BERTRANDOFACILITY TYPE:
735
ADDRESS:3750 LA LUZ RD.TELEPHONE:
(805) 464-4880
CITY:ATASCADEROSTATE: CAZIP CODE:
93422
CAPACITY:4CENSUS: 4DATE:
05/25/2023
UNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Tammy Peterson, House ManagerTIME COMPLETED:
10:15 AM
ALLEGATION(S):
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Staff dragged resident causing bruising.
INVESTIGATION FINDINGS:
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On 5/25/23 at 9:40 am, Licensing Program Analyst (LPA) Chavez conducted an unannounced follow-up visit to deliver final findings for an original complaint dated 5/15/23. LPA met with Tammy Peterson, House Manager, and explained the reason for the visit.

On the allegation, ”Staff dragged resident causing bruising,” the complainant’s concern was that Staff #1 (S1) placed their hands under Client #1’s (C1) arms and dragged C1 from outside the facility into the facility for several feet causing bruising on C1’s arm. To investigate, LPA interviewed the administrator and staff.

On 5/19/23 at 4:35 pm, LPA interviewed Debbie Bertrando, Administrator. Administrator states that she did an investigation into the matter and the results are that S1’s actions were not to intentionally harm C1, however, S1’s escort on C1 resulted in C1 being bruised. Administrator explains that S1’s actions are against policy. Continued on 9099-C.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Darlene Chavez
LICENSING EVALUATOR SIGNATURE:

DATE: 05/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/25/2023
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 3
Control Number 29-AS-20230515163632
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: OPTIONS - LEGATO HOME
FACILITY NUMBER: 405802297
VISIT DATE: 05/25/2023
NARRATIVE
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On 5/16/23 between 10:46 am and 11:23 am, LPA spoke with staff. Staff state they observed bruising on C1’s inner right arm within three days of the incident. Staff describe the bruising as two bruises on the bi-cep of the right arm, approximately a thumb-size or quarter size, 3-4 inches apart from each other. Staff state they spoke with C1 about the bruising, and C1 stated they did not have any pain or discomfort. Staff say that the protocol when trying to move residents to safety is for staff to offer their arm to the client and allow the client to grab their arm for support. Staff say their training is that there should be no other touching of clients but rather to redirect, and that the only time a client should be touched is if staff are preventing clients from harm.

On 5/18/23 at 9:07 am, LPA interviewed staff. Staff say they witnessed S1 behind C1’s back, walking backwards pulling C1 from the front door to the kitchen using their hands under C1’s arms, then lifting C1 up, and walking C1 to their room. Staff say they questioned S1 about their method of assisting C1, and S1 did not respond. Staff say they checked on C1 to make sure they were okay and said C1 was okay, no bruising. Staff say they didn’t consider S1’s actions as abuse, but that S1 didn’t handle the situation the right way. Staff say protocol in that type of situation is to “Not touch residents, only if they are falling. Do not put hands on them, evade.”

On 5/16/23, LPA attempted to observe C1’s arm where the bruising was said to occur and interview C1. C1 was asleep, staff were unable to wake C1, and C1 had long sleeve clothing covering their arms.

Based on the evidence obtained, the allegation, “Staff dragged resident causing bruising,” is deemed Substantiated at this time. Deficiency cited.

Exit interview conducted, report given.

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Darlene Chavez
LICENSING EVALUATOR SIGNATURE:

DATE: 05/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/25/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 29-AS-20230515163632
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: OPTIONS - LEGATO HOME
FACILITY NUMBER: 405802297
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/25/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/26/2023
Section Cited
CCR
80072(a)(1)
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Personal Rights
(a) Except for ....each client shall have personal rights which include...(1) To be accorded dignity in his/her personal relationships with staff and other persons.
The requirement was not met as evidence by:
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Licensee will conduct personal rights training with staff and send a copy of the training sign-in sheet to CCL. Licensee will send a commitment to CCL by 5/26/23 indicating the training will be completed by 5/30/23.
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Based on interviews, the licensee did not meet the regulation cited above in that S1 physically bruised C1 while trying to assist which poses an immediate health and safety and personal rights risk to clients 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: Darlene Chavez
LICENSING EVALUATOR SIGNATURE:

DATE: 05/25/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/25/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3