425801658-3-13-2023-29-AS-KBUY-CQD4WG-20230328192755

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 425801658
Report Date: 03/13/2023
Date Signed: 03/13/2023 11:42:07 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
01/24/2023 and conducted by Evaluator Jeannette Olson

COMPLAINT CONTROL NUMBER: 29-AS-20230124162800

FACILITY NAME:	LE-NA' RESIDENTIAL #5		FACILITY NUMBER:	425801658
ADMINISTRATOR:	ESTELLA USHER		FACILITY TYPE:	735
ADDRESS:	1448 WEST CALLE MARGARITA		TELEPHONE:	(805) 287-9473
CITY:	SANTA MARIA	STATE: CA	ZIP CODE:	93458
CAPACITY:	4	CENSUS: 3	DATE:	03/13/2023
		UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Estella Usher, Administrator		TIME COMPLETED:	11:50 AM

ALLEGATION(S):

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Staff does not treat resident with dignity and respect.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Olson conducted an unannounced subsequent complaint visit to issue final findings on the allegation above. LPA conducted the investigation with Tri-Counties Regional Center Quality Assurance Specialist (QAS) Vincent Figueroa and interviewed Family Memeber on 2/1/23, staff 1 and clients on 2/2/23, Staff 2 on 3/7/23, and Witness on 3/7/23. LPA met with Administrator and explained the purpose of the visit.

On the allegation: Staff does not treat resident with dignity and respect, it was alleged on 1/20/23 Client 1 (C1) was having a crisis when Staff 1 (S1) started teasing C1, made faces, and dared C1 to pull out their tooth. LPA and QAS interviewed Client 1 on 02/03/2023 who stated they were upset because they couldn’t go to their cousin’s birthday party and Staff 1 started to mess with them, “dared me to pull out my tooth. I shouldn’t have listened but I did. (S1) made faces at me.” LPA asked how they made their tooth loose, was it loose prior? C1 stated it wasn’t loose but they used the kitchen counter, got on their knee’s and pushed it, they used a water bottle to wiggle and snap it out. Contined on 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Jeannette Olson
LICENSING EVALUATOR SIGNATURE:	DATE: 03/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/13/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20230124162800

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: LE-NA' RESIDENTIAL #5	FACILITY NUMBER: 425801658
	VISIT DATE: 03/13/2023

NARRATIVE

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When asked how long it took C1 said “a couple of hours and no one stopped me.” LPA asked what faces staff made and C1 stated goofy, dumb faces. When asked what staff was doing while C1 was loosening their tooth C1 stated they were on their phone and after it came out S1 said “Good Job”. QAS asked who’s idea was it to get it loose? C1 stated “it was my idea and I got it loose.” QAS asked What made you think of it? C1 stated, “I feel guilty and I regret it, I won’t get a good Job. (S1) dared me to do it, dared me. (S1) was standing there watching me then [Client 2] (C2) was in the back and getting food in the kitchen and went back to the room. (S1) was in (C2’s) room and (Administrator) was at the Pharmacy. (S1) called (Administrator) when it came out and asked me about it and then took me to Urgent Care.” LPA asked about their other tooth that was pulled out and C1 stated, oh yeah, I pulled out my tooth before I moved into this home because I was mad.

LPA and QAS interviewed Staff 1 on 2/2/23 who stated Client 1 had come out of their room that morning, went to the phone, threw it down and then stormed out of the house. Staff 1 called the Administrator to come assist and followed C1 and convinced them to come home. They got home and Administrator is there and convinced C1 to take a shower and have breakfast. S1 stated they were helping Client 2 get up and dressed and went into the kitchen to grab C2’s breakfast and sees C1 with their hand on their teeth then a can on their teeth. S1 said they thought C1 was just picking their tooth because some food got stuck. S1 stated that then they came back to get cereal for C2 and C1 is hitting their tooth with a can and asked what they are doing? What’s wrong with your teeth? Does it hurt? C1 replies, “you don’t think I can do it? I can pull out my teeth, I can pull out my teeth. Nothing is wrong, I’m going to pull it out.” S1 stated they think their questions were taken as a challenge. S1 stated they told C1 to go to their room and listen to music. They then came back and C1 is in the bathroom missing a tooth. S1 stated they immediately called the Administrator and witnessed no blood anywhere and when asked where the tooth was C1 stated if fell in the sink and said “what, you didn’t think I could do it”. The Administrator had S1 take C1 to the Urgent Care to make sure there was no infection. S1 said they got a phone call a few days later from the Administrator asking if they ever dared C1 to pull out their tooth and said no, there is no way and never said good job or way to go after it came out.

LPA and QAS interviewed Staff 2 (S2) on 3/7/23 who stated they were at the facility on 1/20/23 and was leaving at 9am when C1 left. S2 stated there was nothing odd about that day and they only work 6am-9am and rarely see C1 and S1 interact.
Continued on 9099-C

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Jeannette Olson
LICENSING EVALUATOR SIGNATURE:	DATE: 03/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/13/2023

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20230124162800

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: LE-NA' RESIDENTIAL #5	FACILITY NUMBER: 425801658
	VISIT DATE: 03/13/2023

NARRATIVE

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When asked if they believe the allegation staff does not treat resident with dignity and dared C1 to pull out their tooth, S2 stated that C1 is the jokester and usually daring people or doing pranks so they think the dare came from C1, not S1.

LPA and QAS interviewed Administrator on 2/2/23 who stated they left at 10 AM after calming C1 down, offered to help C1 shower then made C1 some cereal. Administrator then stated they had to go to the Pharmacy and was gone maybe 15 minutes at the most and when they came back the tooth was out but it was strange because there was no blood. Administrator said they took C1 to urgent care and got the next available dentist appointment for 1/25/23. Administrator stated they had a meeting with the family and Care Team on 1/25/23 and that’s when C1’s Family Member (FM) brought up the allegation against S1, stating they dared C1 to take out the tooth. Administrator said that during the meeting C1 asked their Family Member to step out for a minute and C1 told the team that they were mad at (FM) and so made up the story about S1 daring them to pull out the tooth and it was their idea.

LPA interviewed a witness on 3/7/23 who was at the meeting with the family and facility on 1/25/23. Witness stated that C1 asked their Family Member to step out and not get mad. C1 then said they pulled out their tooth because they were upset with FM because they wouldn’t let them go to their cousin’s birthday party after C1 stole some items from FM’s home. A few minutes later FM came back into the room and a second Family Member asked C1 to share what they told them. C1 then said, “oh yeah, (S1) dared me to pull it out.” LPA and QAS asked Witness if they thought the staff had instigated or encouraged this at all and Witness stated from what they know of the home and the staff they didn’t think it was them. Witness stated they looked up C1’s file and notes and saw that C1’s move in date to the current facility had to be pushed back because C1 had pulled out a tooth, so it’s a behavior they had prior to living at the facility. Based on the information obtained the allegation: Staff does not treat resident with dignity and respect is Unsubstantiated at this time. However, a Case Management Visit will be conducted to address the lack of supervision during the incident.

Exit interview conducted, copy of the report was emailed and printed.

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Jeannette Olson
LICENSING EVALUATOR SIGNATURE:	DATE: 03/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/13/2023

LIC9099 (FAS) - (06/04)

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