425850024-10-11-2022-29-AS-KBUY-CKCPMQ-20221019112640

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 425850024
Report Date: 10/11/2022
Date Signed: 10/11/2022 04:25:08 PM

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
10/06/2022 and conducted by Evaluator Jeannette Olson

COMPLAINT CONTROL NUMBER: 29-AS-20221006114509

FACILITY NAME:	POLLY'S HOUSE		FACILITY NUMBER:	425850024
ADMINISTRATOR:	JENNIFER GODDARD		FACILITY TYPE:	735
ADDRESS:	1801 BATH ST		TELEPHONE:	(805) 884-8440
CITY:	SANTA BARBARA	STATE: CA	ZIP CODE:	93101
CAPACITY:	12	CENSUS: 10	DATE:	10/11/2022
		UNANNOUNCED	TIME BEGAN:	09:40 AM
MET WITH:	Nick Papageorge, Backup Administrator		TIME COMPLETED:	04:15 PM

ALLEGATION(S):

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Staff financially abused resident
Staff are tampering with Resident's personal items.

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPAs) Cortez and Olson conducted an unannounced 10-day complaint visit to investigate the allegations above. LPA’s met with back up Administrator Nick Papageorge and explained the purpose of the visit.

LPAs requested revellent documents and interviewed 7 clients, Administrator, and 2 Staff.

On the allegation: Staff financially abused resident. It was alleged that Staff (S1) used Client 1 (C1)’s social security number and is “tapping” into their bank account. LPA’s interviewed Administrator who stated that S1 is on medical leave and C1 has had an up and down relationship with S1. Administrator stated S1 is a Licensed Associate Marriage and Family Therapist and the way S1 interacts with C1 is totally appropriate. Administrator stated that C1 has made a lot of claims recently against S1, but thought it was because of the conflict caused by S1 being strict and setting boundaries with C1.
Continued on 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Jeannette Olson
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)

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Control Number 29-AS-20221006114509

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: POLLY'S HOUSE	FACILITY NUMBER: 425850024
	VISIT DATE: 10/11/2022

NARRATIVE

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C1 was recently hospitalized due to behaviors and was unable to be interviewed. LPA asked if staff or the facility have access to clients financials and Administrator stated no. Most clients have Pro Pay that handles their finances and there is no bank account or any way for residents or staff to access the money. If there are any left over cash after paying rent and other bills then the excess money is dispersed to the clients and the client's can choose if the facility assists or not. LPA reviewed C1’s physician’s report, which indicates their conservator manages C1’s cash resources. LPA requested to see the records of residents excess cash and Client 1 did not have any on file or any record of the facility receiving any excess cash since Client 1 was admitted in 2019. LPA reviewed other client’s cash records and observed the kept records appeared to be accurate. LPA learned that C1 directly receives any extra money and chooses to not have the facility handle it. Based on interviews and record review, facility staff do not have access to client’s bank account information. Therefore the allegation is deemed Unsubstantiated at the time.

On the allegation: Staff are tampering with residents personal items. It was alleged that staff are putting additives into residents soap and shampoo which is causing residents hair to fall out. LPA’s Olson and Cotez interviewed 7/10 residents that stated they get their soap and shampoo mainly from family but the facility offers basic hygiene items. All 7 residents interviewed did not have any concerns about staff or others adding things to their soap and shampoo. LPAs observed Nexus, Pantene, CVS brand and Garnier Fructis in the residents rooms and showers. Staff interviews revealed that no staff have seen or heard of any other staff putting additives into residents soap or shampoo. Based on observation and interviews this allegation is deemed Unsubstantiated at the time.

Exit interview conducted, a copy of the report was emailed to Administrator.

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Jeannette Olson
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)

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