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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 405850037
Report Date: 08/18/2022
Date Signed: 08/18/2022 01:15:05 PM

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
12/20/2021 and conducted by Evaluator Rachael De Leon
COMPLAINT CONTROL NUMBER: 29-AS-20211220132247
FACILITY NAME:LA LOMA HOMEFACILITY NUMBER:
405850037
ADMINISTRATOR:JEANETTE MACKFACILITY TYPE:
735
ADDRESS:1151 LA LOMA DRTELEPHONE:
(805) 723-5104
CITY:NIPOMOSTATE: CAZIP CODE:
93444
CAPACITY:4CENSUS: 4DATE:
08/18/2022
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Justin Penrod, Back up to AdministratorTIME COMPLETED:
01:20 PM
ALLEGATION(S):
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Resident was hit by another resident in care.
Resident was bit by another resident in care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) De Leon conducted a subsequent complaint visit to deliver final findings of the allegations. LPA met with Justin Penrod Back Up Administrator and explained the purpose of the visit.

LPA De Leon conducted the initial 10-day Complaint visit on 12/23/2021 toured facility, requested documentation and interviewed residents from 12:00pm-2:00pm. LPA De Leon conducted further interviews with Miguel Magana Quality Assurance for Tri-Counties Regional Center (TCRC) on 12/29/2021 at 9:02 am and 10:14am with staff. LPA De Leon interviewed staff on 12/17/2021 and 12/29/2021 around 4:45pm. LPA De Leon reviewed documentation on 08/17/2022 from the facility, San Luis Obispo’s Sheriff incident reports from 12/11/2021 and 12/16/2021, and TCRC Residential Facility Investigation Report and Corrective Action Plan dated 03/03/2022. Cont. 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Rachael De Leon
LICENSING EVALUATOR SIGNATURE:

DATE: 08/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2022
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-20211220132247
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: LA LOMA HOME
FACILITY NUMBER: 405850037
VISIT DATE: 08/18/2022
NARRATIVE
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On the allegation: Resident was hit by another resident in care. LPA De Leon conducted interviews with staff and residents that revealed resident 1 hit another resident 2 (R2) several times in the head and body, R1 also threw property at staff 1 (S1) and struck staff 2 (S2), 911 was called and the Sheriff’s office and paramedics responded to the address. Sheriff’s office and TCRC reports support the findings of R1 hitting R2. Facility reported this incident on 12/11/2021 within 24 hours and followed up with a written report the following day. An additional incident report was submitted for 12/16/2021 where R1 hit R2, no injuries, 911 was called and R1 was taken for a 5150 Hold. Based on the evidence this allegation is deemed Substantiated at this time.

On the allegation: Resident was bit by another resident in care. LPA De Leon conducted interviews with staff and residents that revealed R1 bit R2 in the shoulder. Sheriff’s office responded to the 911 call and R2 was taken to the hospital treated and released for injuries caused by R1. LPA De Leon reviewed evidence containing photographs of R2’s bite injury, it was red, swollen, purple and bruising. Sheriff’s office and TCRC’s reports support the findings of R1 biting R2. LPA reviewed documentation collected from facility incident reports and R2’s medical records revealing R2 had sustained a bit. Based on the evidence this allegation is deemed Substantiated at this time.

Exit interview conducted, deficiencies cited, copy of report and appeal rights emailed to Administrator
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Rachael De Leon
LICENSING EVALUATOR SIGNATURE:

DATE: 08/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 29-AS-20211220132247
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: LA LOMA HOME
FACILITY NUMBER: 405850037
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/18/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/22/2022
Section Cited
CCR
80072(a)(3)
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(a)...each client shall have personal rights...the following:(3)To be free...unusual punishment, infliction of pain, humiliation, intimidation,... This requirement was not met as evidenced by:
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Administrator agreed to train all staff in Personal Rights 80072 & 85072 and proof with all staff signatures and up to date LIC 500 as well as hold a meeting with residents to discuss their personal
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Based on interviews and documentation the Licensee did not comply, R1 hit R2 on two separate occasions which possesses an immediate personal rights risk to residents in care.
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rights with each of them, any representatives and provide proof of this meeting to CCL.
Type A
08/22/2022
Section Cited
CCR
85165(d)(1-6)
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(d)...(1)...(2)Methods of de-escalating volatile situations... non-physical intervention techniques...crisiscommunication; or evasive techniques.(3)...(4)...(5)...(6)...This requirement was not met as evidenced by:
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Administrator agreed to have all staff trained in regulation 85165 Emergency Intervention provide proof of training, and up to date LIC 500 with proof of training and all staff signatures.
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Based on interviews and documentation the Licensee did not comply with the regulations above R1 was able to bite R2 without staff intervention, S1 and S2 were not up to date on their training which poses an immediate health, safety and personal rights risk to residents in care.
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All staff need to be up to date in all training requirements annually and upon hiring.
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: Rachael De Leon
LICENSING EVALUATOR SIGNATURE:

DATE: 08/18/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2022
LIC9099 (FAS) - (06/04)
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