425850008-8-7-2024-29-AS-KBUY-D8JVBT-20240827161802

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 425850008
Report Date: 08/07/2024
Date Signed: 08/07/2024 03:30:16 PM

Substantiated

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
07/09/2024 and conducted by Evaluator Brian Phillips

COMPLAINT CONTROL NUMBER: 29-AS-20240709120029

FACILITY NAME:	MOMENTUM WORK, INC. LAKESIDE		FACILITY NUMBER:	425850008
ADMINISTRATOR:	JUDY LINARES		FACILITY TYPE:	735
ADDRESS:	423 MONTEREY RD		TELEPHONE:	(805) 566-9000
CITY:	SANTA MARIA	STATE: CA	ZIP CODE:	93455
CAPACITY:	4	CENSUS: 4	DATE:	08/07/2024
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Edward Maldonaldo, Residential Director and Jrisalda Escamilla, Program Manager		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Staff did not provide adequate care and supervision to a client
Staff did not properly report an incident involving a client

INVESTIGATION FINDINGS:

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On 08/07/2024, Licensing Program Analyst (LPA) Brian Phillips conducted an unannounced subsequent complaint investigation visit to the facility above. LPA Phillips met with Residential Director Edward Maldonaldo and Program Manager Jrisalda Escamilla, and explained the reason for the visit.

On the allegation: Staff did not provide adequate care and supervision to a client. It is alleged that on 06/29/2024, Law Enforcement responded to a gas station on a busy street regarding a welfare check request of a subject who was wandering around in the parking lot of the gas station without shoes or a jacket. The allegation states that there were concerns about the subject’s state of mind. The subject, Client #1 (C1) of the facility above, was missing for at least 30 minutes in an area that has a large volume of vehicular traffic and countless hazards that could have led to their injury or death.

On 07/01/2024, the Department received a Law Enforcement Agency reported Unusual Incident/Injury Report (UIR) regarding C1 eloping from the facility on 06/29/2024. Continued on 9099-C

Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Brian Phillips
LICENSING EVALUATOR SIGNATURE:	DATE: 08/07/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/07/2024

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-20240709120029

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: MOMENTUM WORK, INC. LAKESIDE	FACILITY NUMBER: 425850008
	VISIT DATE: 08/07/2024

NARRATIVE

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Law enforcement deputies arrived at the elopement location and recognized the subject as C1 who had previously been located at the same location from an elopement in August 2023. During follow up at the facility by Law Enforcement on 06/29/2024 after C1’s elopement, it was reported that C1 was allegedly able to leave the residence because one facility Staff member was asleep and the other was watching their cell phone and not paying attention to their surroundings. A subsequent UIR reported by the facility to the Department on 07/01/2024 stated that Staff did not know that C1 had eloped from the facility until returned by Law Enforcement. The documented facility "line of sight requirement" for C1 states that Law Enforcement must be contacted if C1 is unsupervised and out of sight of Staff. Law Enforcement was not contacted at any time by Staff during the elopement of C1. LPA was informed by the Licensee that the same employee was on duty during the elopement by C1 in August 2023 and the recent elopement on 6/29/2024. C1 stated to Law Enforcement that they were almost hit by car during elopement on 06/29/2024.

On 07/09/2024, Licensing Program Analyst (LPA) Brian Phillips arrived at the facility unannounced to conduct an initial complaint visit. The LPA conducted a physical tour to make sure the auditory alarm systems in place in the facility were in working order. The LPA also requested and received documents pertinent to the complaint allegation. The Tri-Counties Regional Center (TCRC) Resident Placement Information, dated 02/25/2019, indicates that C1 has a propensity for wandering/AWOL behavior that requires constant redirection to keep the client and others safe. The Functional Capability Assessment for C1 dated 04/29/2024 indicates C1 is required to have "Line of Sight" supervision that has a protocol to inform Law Enforcement. The TCRC Individualized Program Plan (IPP) for C1 states that C1 needs a high level of care and close supervision throughout the day. C1 requires proximity of support to avoid elopement. The current auditory alarm system in place on doors that exit the facility was observed to be in sufficient working order and appropriate level of noise. The facility has a documented Behavioral Consulting Missing Person’s Plan/Elopement Plan for C1, updated as of May 2023, that provides a protocol for Staff when C1 leaves without supervision and is in sight of Staff, or when C1 leaves without supervision and is out of sight of Staff. Through interview with facility Staff, Law Enforcement, and record review, LPA learned that C1 has a documented history of wandering behavior/elopement known by the facility and Staff on duty during the elopement of C1 on 06/29/2024. C1 has a current documented facility Missing Person’s Plan/Elopement Plan that was not followed by facility Staff.

Based on the information obtained, there was sufficient evidence to show Staff did not provide adequate care and supervision to a client. Therefore, the allegation is deemed Substantiated at this time. Contd. 9099-C

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Brian Phillips
LICENSING EVALUATOR SIGNATURE:	DATE: 08/07/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/07/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 29-AS-20240709120029

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: MOMENTUM WORK, INC. LAKESIDE	FACILITY NUMBER: 425850008
	VISIT DATE: 08/07/2024

NARRATIVE

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On the allegation: Staff did not properly report an incident involving a client. It is alleged that Client #1 (C1) has a “line of sight” requirement in a documented Behavioral Consulting Missing Person's Plan/Elopement Plan, with specific protocol not followed by the Staff on duty during C1’s elopement.

As of May 2023, the current documented facility Behavioral Consulting Missing Person’s Plan/Elopement Plan for C1 provides a protocol for Staff when C1 leaves without supervision and is in or out of line of sight. If C1 is out of sight of Staff, at least one staff member should stay with the other clients in the facility. Staff will search the immediate area including the van, restroom, etc. If C1 is not found within 5 minutes, staff will call the administrator/supervisor and director. If C1 is not found within 10 minutes, immediately call 911. A search party will be organized by the administrator or supervisor. The emergency contact list will be phoned regarding reporting or locating the missing person. This list includes the local police department, public transportation agencies, local fire department, and local hospitals. If elopement occurs during night hours (from 9PM – 6AM), call 911 within 5 minutes. During the elopement of C1 on 06/29/2024, 911 and/or law enforcement was never called, and C1 was out of sight of the Staff for over 30 minutes. Staff interviewed by LPA stated that during the time of the incident, they went to the restroom at 4:30am and heard the auditory alarm go off on the bedroom door of C1. Staff stated to LPA that they did not hear the auditory alarm that goes off when the hallway door is opened in the facility. Staff noticed C1's bedroom door was open and observed that C1 was nowhere in their bedroom. As two (2) Staff were on duty at the time of the incident, one Staff stated that they stayed back at the facility to help other clients with breakfast while the other Staff member left in their car to look for C1. Approximately 30 minutes later, Law Enforcement knocked on the door of the facility and helped bring C1 back to their room. Staff stated that they gave the law enforcement deputies the correct contact information for the Administrator and management of the facility. Both Staff members on duty during the elopement of C1 on 06/29/2024 stated they called management of the facility, but only one Staff member stated they left a voicemail message for Tri-Counties Regional Center (TCRC), and stated they attempted to leave a voicemail message for the LPA of the facility.

Based on the information obtained, there was sufficient evidence to show Staff did not provide adequate care and supervision to a client. Therefore, the allegation is deemed Substantiated at this time.

Exit interview conducted, deficiencies cited, copy of this report and appeal rights provided to facility.

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Brian Phillips
LICENSING EVALUATOR SIGNATURE:	DATE: 08/07/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/07/2024

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 29-AS-20240709120029

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: MOMENTUM WORK, INC. LAKESIDE	FACILITY NUMBER: 425850008
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/07/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 08/08/2024 Section Cited CCR 80078(a)	1 2 3 4 5 6 7	80078 Responsibility for Providing Care and Supervision: (a) The licensee shall provide care and supervision as necessary to meet the client's needs. This requirement is not met as evidenced by: Based on interviews and records review, the licensee did not comply with the section cited above.	1 2 3 4 5 6 7	The licensee will submit a plan describing how they will ensure all staff know the documented protocols for clients who require additional supervision while in care. Submit proof to CCL by 8/8/2024. Licensee will inform LPA of the progression of a proposed outdoor facility surveillance system.
	8 9 10 11 12 13 14	Licensee failed to supervise client with documented AWOL plan/history, client eloped on 6/29/2024 without knowledge of Staff, who failed to contact law enforcement per facility protocol while client in a hazardous area, which posed an immediate health and safety risk to residents in care.	8 9 10 11 12 13 14
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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: Brian Phillips
LICENSING EVALUATOR SIGNATURE:	DATE: 08/07/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/07/2024

LIC9099 (FAS) - (06/04)

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