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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 425801987
Report Date: 11/18/2021
Date Signed: 11/18/2021 03:06:57 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
06/02/2021 and conducted by Evaluator Arien Diaz
COMPLAINT CONTROL NUMBER: 29-AS-20210602171655
FACILITY NAME:UCP WORK, INC-ROSEFACILITY NUMBER:
425801987
ADMINISTRATOR:PAMELA HOLCOMBEFACILITY TYPE:
735
ADDRESS:434 E. ROSE AVENUETELEPHONE:
(805) 614-0967
CITY:SANTA MARIASTATE: CAZIP CODE:
93454
CAPACITY:4CENSUS: 3DATE:
11/18/2021
UNANNOUNCEDTIME BEGAN:
10:11 AM
MET WITH:Pam HolcombeTIME COMPLETED:
11:10 AM
ALLEGATION(S):
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Staff sprayed resident with a water hose.
Staff did not treat resident with dignity and respect.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Diaz conducted a complaint visit to deliver final findings of the complaint investigation conducted by LPA Diaz.

LPA Diaz reviewed facility documents and conducted interviews with staff and residents. LPA interviewed clients on 06/03/21 at 3:38pm, 4:19pm, and 4:43pm. LPA interviewed staff on 10/17/21 at 3:48pm. LPA interviewed staff on 11/03/21 at 2:29pm, 2:43pm, and 3:00pm. LPA interviewed staff on 11/4/21 at 11:15am. On the allegation: Staff sprayed resident with a water hose. 5 out of 5 staff members stated they saw a video on social media involving 2 former staff members and 1 client at the facility. All 5 staff members consistently described the video to display Staff 1 (S1) spraying Client 1 (C1) with a water hose in the backyard. C1 was screaming and crying and S1 continued to spray C1 with water. According to the staff, the video also showed S2 holding the sliding glass door shut, while laughing and not allowing C1 inside the facility. S2 was laughing while watching S1 spray C1.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Arien Diaz
LICENSING EVALUATOR SIGNATURE:

DATE: 11/18/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2021
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-20210602171655
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: UCP WORK, INC-ROSE
FACILITY NUMBER: 425801987
VISIT DATE: 11/18/2021
NARRATIVE
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According to the clients, S1 and S2 usually work at the same time and both S1 and S2 sprayed C1 with water on the back patio. According to the client, they saw S1 and S2 mistreat C1 outside and the police arrived at the facility because C1 was mistreated. The Administrator stated the video was posted on 5/31/21, and the Administrator immediately notified the police, the executive director and put S1 and S2 on administrative leave; S1 and S2 will not be returning to work at the facility. The Administrator also provided the police with the video. LPA observed the video and confirmed statements from staff and the Administrator. Based on the interviews, on the allegation: Staff sprayed resident with a water hose is deemed substantiated at this time.

On the allegation: Staff did not treat resident with dignity and respect. 5 out of 5 staff members stated that C1 was mistreated by S1 in the video. All staff stated that S1 was not treating the client with dignity or respect. All staff members stated that they would never mistreat a client and spray them with water. According to the clients, they saw S1 and S2 mistreat C1 outside and the police arrived at the facility because C1 was being mistreated. The Administrator stated S1 was mistreating C1 and S2 is shown not stopping the mistreatment from happening. LPA observed the video and confirmed statements from the staff and Administrator. Based on the interviews, on the allegation: Staff did not treat resident with dignity and respect is deemed substantiated at this time.

Exit interview, deficiencies cited, report given, appeal rights given.

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Arien Diaz
LICENSING EVALUATOR SIGNATURE:

DATE: 11/18/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 29-AS-20210602171655
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: UCP WORK, INC-ROSE
FACILITY NUMBER: 425801987
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/18/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/18/2021
Section Cited
CCR
80072(a)(3)
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80072(a)(3) To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse, or other actions of a punitive nature, including but not limited to: interference with the daily living functions, including eating, sleeping, or toileting; or withholding of shelter, clothing, medication or aids to physical functioning. This requirement is not met as evidenced by:
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S1 and S2 were terminated after the incident. Facility staff received Mandated reporting training and ProAct Training. Copy of this training will be submitted to CCL by POC due date 11/23/21.
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Based on interview and video evidence, the licensee did not ensure S1 and S2 did not abuse C1 by hosing C1 outside, which posed an immediate safety and personal rights risk to residents in care.
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Type A
11/18/2021
Section Cited
CCR
80072(a)(1)
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80072(a)(1) To be accorded dignity in his/her personal relationships with staff and other persons.
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Licensee agreed to provide staff training on personal rights and how to treat residents with dignity and respect. Copy of this training to be submitted to CCL by POC due date 11/23/21
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Based on interviews and video evidence, licensee failed to ensure that S1 and S2 treated resident 1 (R1) with dignity and respect, which posed an immediate safety and personal rights risk to residents 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: Arien Diaz
LICENSING EVALUATOR SIGNATURE:

DATE: 11/18/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2021
LIC9099 (FAS) - (06/04)
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