425801208-1-11-2024-29-AS-KBUY-CZYSSF-20240130130754

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 425801208
Report Date: 01/11/2024
Date Signed: 01/11/2024 12:32:31 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS NORTH, 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
10/04/2023 and conducted by Evaluator Brian Phillips

COMPLAINT CONTROL NUMBER: 29-AS-20231004143919

FACILITY NAME:	LE-NA' RESIDENTIAL HOME #3		FACILITY NUMBER:	425801208
ADMINISTRATOR:	ESTELA USHER		FACILITY TYPE:	735
ADDRESS:	475 WILSON COURT		TELEPHONE:	(805) 934-2167
CITY:	SANTA MARIA	STATE: CA	ZIP CODE:	93455
CAPACITY:	4	CENSUS: 4	DATE:	01/11/2024
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Estella Usher, Administrator		TIME COMPLETED:	11:00 AM

ALLEGATION(S):

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Staff physically assaulted resident which resulted in a fracture
Staff yelled at residents

INVESTIGATION FINDINGS:

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On 01/11/2024, Licensing Program Analyst (LPA) Brian Phillips conducted a subsequent complaint visit to deliver findings for the above allegations. LPA met with Administrator Estella Usher, and explained the reason for the visit.

On the Allegation Staff physically assaulted resident which resulted in a fracture: On 10/04/2023, the Department received a complaint regarding an allegation of Physical Abuse. It was alleged that Staff #1 (S1) and Staff #2 (S2) grabbed and pulled Resident #1 (R1) resulting in a fractured arm. The complaint was referred to the Community Care Licensing (CCL) Investigations Branch (IB) and assigned to Investigator Peter Zertuche.

On 10/05/2023, from 9:15am to 1:30pm, Licensing Program Analyst (LPA) Brian Phillips conducted an initial complaint visit to the facility to initiate the investigation. Continued on 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Brian Phillips
LICENSING EVALUATOR SIGNATURE:	DATE: 01/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/11/2024

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 4

Control Number 29-AS-20231004143919

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS NORTH, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: LE-NA' RESIDENTIAL HOME #3	FACILITY NUMBER: 425801208
	VISIT DATE: 01/11/2024

NARRATIVE

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LPA Phillips met with Administrator Estella Usher and explained the purpose of the visit. The LPA toured the facility and observed two (2) residents in care. The LPA requested documents pertinent to the investigation. The LPA noted further investigation was required and advised the complaint would be investigated by the Community Care Licensing (CCL) Investigations Branch (IB).

On 10/25/2023, from approximately 3:30 to 4:00pm, Investigator Zertuche conducted interviews with the reporting party, and the Tri-Counties Regional Center (TCRC) coordinator; on 10/27/2023, from approximately 10:00am 11:30am, with S1, S2, R1, other facility residents, and the Administrator; and on 11/14/2023, at approximately 10:30am, with R1’s attending physician. Additionally, Investigator Zertuche reviewed Pacific Central Coast Med Plus Orcutt medical records, Santa Maria Police Department (SMPD) report #23-0012205-001, and facility file documents, including Unusual Incident Reports (UIRs), related to R1.

A review of R1’s facility records indicated R1 is ambulatory with a diagnosis of profound intellectual disability and seizure disorder. R1 has occasional confusion and requires assistance for most daily living activities. R1 has a history of physical aggression, self-injurious behaviors, and fabricating stories. R1 can communicate using simple sentences and gestures. R1 has an unsteady gait and is assigned a 1 to 1 staff ratio. R1’s behavior support plan indicates staff should remain within arm’s reach to prevent falls.

The medical records reviewed documented R1 sustained a fractured right wrist and the notes indicated R1 has a development delay and did not know how the injury occurred. According to the report, likely causes are an accident (car, bike, etc.), sports injuries or a fall with the arm outstretched. Notes indicated that R1 disclosed to the caregiver that someone pushed them, but the incident was unwitnessed. The doctor stated there was no way of knowing for sure how R1 sustained the fracture.

According to the incident report submitted by the facility, on 09/28/2023, R1 arrived at the facility from the day program at 3:00pm. R1 informed S1 and the Administrator that a person from the day program pushed them down. When S1 checked R1, S1 observed that R1 was unable to hold their water bottle to take their meds. S1 immediately texted and called the day program to determine what happened. At 3:33pm the day program returned the call stating that “R1 did not fall at day program, R1 was unsteady, R1 was about to hit their head against the edge of a table, when staff immediately grabbed R1 so they would not get hurt”. Continued on 9099-C

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Brian Phillips
LICENSING EVALUATOR SIGNATURE:	DATE: 01/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/11/2024

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20231004143919

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS NORTH, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: LE-NA' RESIDENTIAL HOME #3	FACILITY NUMBER: 425801208
	VISIT DATE: 01/11/2024

NARRATIVE

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The incident report further documented that R1 then continued their evening routine. On 09/29/2023, R1 went to day program, returned home still complaining their hand hurt. Staff then observed R1 throughout the evening and weekend, where staff observed R1’s hand getting more swollen. On Monday 10/02/2023, R1 went to day program, returned home and S1 immediately took R1 to the urgent care where an x-ray was done and revealed a right hand nondisplaced spiral fracture of distal shaft of right ulna. R1 was sent home in a splint and a referral was made to Central Coast Orthopedic.

The incident report received from R1’s day program did not indicate R1 had any fall at the day program, only that the day program was informed by the facility on 10/03/2023, that R1 was diagnosed with a fractured hand and would not be attending day program for a few days. The incident report addendum further detailed that the day program did not observe R1 complaining of any pain on 09/29/2023. On 10/02/2023, R1 stated their hand hurt, the day program observed R1’s hand to be slightly swollen, but R1 continued with their daily activities without complaining of hand hurting. The day program contacted S1 at 1:27pm to inform them of the observations. S1 then stated they would take R1 to urgent care after day program.

The investigation revealed there were no witnesses to abuse, and R1 denied mistreatment by staff stating the incident occurred at day program. Another resident, who initially alleged the incident occurred at home, denied witnessing abuse. All other residents denied abuse as well as facility staff members. The doctor reported R1 had a swollen arm but did not recall any bruising or marks on R1’s arm. The doctor was unable to determine how R1 fractured their forearm. The SMPD closed the case as inactive/documentation only and referred the incident to Adult Protective Services (APS).

The Department found insufficient evidence to support the allegation, therefore, the allegation “Physical Abuse – Staff physically abused resident resulting in a fractured arm” is deemed Unsubstantiated at this time.
On the allegation: Staff yelled at residents. It was alleged that when Staff #1 (S1) and Staff #2 (S2) grabbed and pulled Resident #1 (R1) resulting in a fractured arm, alleged in allegation #1, the 2 staff members who grabbed R1 by the arm also verbally yelled at R1. The RP stated that R2 reported when the two staff members saw R2’s door was opened, they also verbally yelled at R2.

Continued on 9099-C

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Brian Phillips
LICENSING EVALUATOR SIGNATURE:	DATE: 01/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/11/2024

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 29-AS-20231004143919

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS NORTH, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: LE-NA' RESIDENTIAL HOME #3	FACILITY NUMBER: 425801208
	VISIT DATE: 01/11/2024

NARRATIVE

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On 10/27/2023, R2 was interviewed by the Investigation Branch (IB) of the Licensing Division. R2 stated that they did not witness the injury to R1 and that no Staff members yelled at either resident. R2 reported that staff members treat the residents well and they are nice to the residents. R2 denied anyone mistreating them or any other resident and denied witnessing any Staff member grab or push R1. The investigator asked R2 what happens when a resident gets in trouble and R2 stated that Staff will take the residents’ toys away. On 10/27/2023, IB interviewed R1 about the allegation that Staff verbally yelled at them. R1 was unable to answer questions aside from stating that the injury to their arm occurred at school and not the facility. R1 was unable to provide any details on Staff members allegedly verbally yelling at either R1 or R2 due to limited verbal skills. As IB attempted to ask questions, R1 would only state their name and repeat that the incident occurred at school. On 10/25/2023, when interviewed by IB, S1 stated that R2 has a history of making false allegations and that nothing unusual occurred on the day in question of the complaint allegation. On 10/27/2023, S2 stated during an interview with IB that they had never witnessed any Staff member mistreat either R1 or R2 verbally or physically. During the interview with Staff members on 10/27/2023, IB observed the 2 Staff members alleged to have yelled at residents interacted with other Staff members normally and did not appear to be anxious or in fear. During interview with IB, S3 stated that they had not witnessed any other Staff member mistreat R1 or R2. When asked what type of discipline is used, S3 stated that they use verbal de-escalation techniques. The administrator of the facility was interviewed by IB on 10/27/2023 and denied that any of the Staff members mistreated R1 or R2 or any other resident. When asked about the allegation of Staff yelling at R1 and R2, the Administrator stated that R2 tends to lie. On 10/27/2023, the Individual Support Plan for R2 was obtained, and through record review by the Department indicated that R2 has a history of fabricating stories.

On 01/10/2024, LPA interviewed Staff members of R1's day program and the location where R1 indicated to IB that the injury to their arm occurred. Staff members stated that R1 did not fall at day program, but was unsteady and was about to hit their head against the edge of a table. A Staff member immediately grabbed R1 so they would not get hurt from falling and hitting their head. This information coincides with the incident report submitted by the facility on 09/28/2023. Therefore, there is no evidence to show Staff members verbally yelled at either R1 or R2 during an incident that did not allegedly occur at the facility.

Based on the information obtained, there was insufficient evidence to prove the allegation. Therefore, the allegation is deemed Unsubstantiated at this time.
Exit interview conducted, copy of report provided to facility.

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Brian Phillips
LICENSING EVALUATOR SIGNATURE:	DATE: 01/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/11/2024

LIC9099 (FAS) - (06/04)

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