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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 405850037
Report Date: 10/11/2022
Date Signed: 10/11/2022 11:43:07 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
10/03/2022 and conducted by Evaluator Rachael De Leon
COMPLAINT CONTROL NUMBER: 29-AS-20221003151359
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:
10/11/2022
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Gina Ponce-Owens, Staff CaregiverTIME COMPLETED:
11:50 AM
ALLEGATION(S):
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Due to a lack of supervision, one client bit another client in care
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) De Leon conducted a 10 day complaint visit to the facility above. LPA met with staff and staff called Administrator. Administrator is at another facility and unable to make visit. Administrator will have staff caregiver Gina Ponce-Owen sign report today.

LPA De Leon conducted interviews with residents and staff on 10/11/2022 at 9:40am, 9:47am, 10:15am and 10:25am.

LPA requested the following documents: Staff roster with telephone numbers, Staff Schedule for week of incident, Resident Roster, Resident LIC 602 Physicians Report, TCRC up to date Individual development plan or appraisal needs and services plan.
Continued 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Rachael De Leon
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 2
Control Number 29-AS-20221003151359
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: 10/11/2022
NARRATIVE
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On the allegation: Due to a lack of supervision, one client bit another client in care. LPA conducted interviews with staff and residents which revealed that Resident 1 (R1) was having behaviors that day and R1 was told to finish R1's laundry before bed time. R1 was not complying with staff request. It was during medication time and Staff 2 (S2) was passing medications at the time R1 had just taken medications and it was Resident 2 (R2) turn next. R2 began telling R1 to do R1's laundry, Staff 1(S1) and S2 told R2 to leave R1 alone and not tell R1 what to do, as R1 and R2 were walking down the hall passed the kitchen R2 put R2's hands on R1's shoulders guiding R1 to the laundry area. R1 bite R2 above the wrist below the elbow in the middle of R2's arm. R2 started to cry S1 was able to separate R1 and R2. S1 provided R2 with a Band-Aid, no skin was broken, and no bite marks were present. The facility is a Tri-Counties Regional Center (TCRC) home with behavioral clientele. The staffing that day was two staff which meets the hours requirement set for the facility by TCRC. The facility was not short staffed that day. The incident happened quickly without any indications it would have lead to a resident being bitten, staff acted quickly and separated residents. R1 was scared of R2 size and because R2 has bitten R1 in the past. R1 was not sure what R2 was going to do and got scared so R1 bite R2 and R2 then took R2's hand off of R1. R1 reacted to R2 quickly and S2 was not able to intervene in time. Based on the evidence this allegation is Unsubstantiated at this time.

Exit interview conducted and copy of report emailed to Administrator.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Rachael De Leon
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 2