425850049-4-9-2022-29-AS-KBUY-CDDV57-20220411160727

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 425850049
Report Date: 04/09/2022
Date Signed: 04/09/2022 11:02:22 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
05/21/2021 and conducted by Evaluator Darlene Chavez

COMPLAINT CONTROL NUMBER: 29-AS-20210521155055

FACILITY NAME:	PROVIDENCE RESIDENTIAL HOME		FACILITY NUMBER:	425850049
ADMINISTRATOR:	JEMERSON, ANALIZA V.		FACILITY TYPE:	735
ADDRESS:	1439 WALLIS AVENUE		TELEPHONE:	(805) 720-9577
CITY:	SANTA MARIA	STATE: CA	ZIP CODE:	93458
CAPACITY:	4	CENSUS: 4	DATE:	04/09/2022
		UNANNOUNCED	TIME BEGAN:	10:48 AM
MET WITH:	Analiza Jemerson, Licensee/Administrator		TIME COMPLETED:	11:20 AM

ALLEGATION(S):

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Facility staff refused to accept resident back from the hospital
Facility staff are not meeting resident’s needs

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Chavez conducted an unannounced subsequent complaint visit to deliver final findings. LPA met with Analiza Jemerson, Licensee/Administrator, and explained the purpose of the visit. The investigation was started on 5/27/2021 by LPAs Diaz and Chavez.

During the investigation, LPA Diaz reviewed documentation and interviewed administrator, residents, and a credible witness. The complainant’s concern was that the facility refused to accept the resident back from the hospital and had doubts if the facility could meet the resident’s needs due to Client 1 (C1)’s aggressive behaviors. On 4/27/2021, C1 was hospitalized due to aggressive behaviors. On 4/29/2021 at 5:30pm, the hospital called the administrator and stated C1 needed to be picked up. The administrator picked up C1 from the hospital. On 5/10/2021, C1 had aggressive behavior including repeatedly hitting the countertops with their hand. The administrator called 9-1-1 and C1 was admitted to the hospital around 8pm.

Continued on 9099-C.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Darlene Chavez
LICENSING EVALUATOR SIGNATURE:	DATE: 04/09/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/09/2022

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-20210521155055

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: PROVIDENCE RESIDENTIAL HOME	FACILITY NUMBER: 425850049
	VISIT DATE: 04/09/2022

NARRATIVE

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On 5/11/2021 around 3pm, the hospital stated C1 was ready for discharge and that C1 needed to be picked up quickly, “within the hour.” The administrator stated she would try to pick up C1 within one hour but could be a little late. The administrator also tried calling the hospital later to state she was on her way to pick up C1 but could not get through to the discharge worker. C1 was discharged from the hospital and arrived at the facility between 5pm and 6pm. A credible witness confirmed C1’s needs were met while C1 resided at Providence Residential. C1 had lived at the facility for several months before the incidents where C1 was hospitalized. A plan was made to support C1, and a one-to-one staff was added as well as crisis support and mental health services. The credible witness stated C1 was doing well on the witness’s last visit and believed the facility was meeting C1’s needs. Based on the information obtained, the allegations are deemed unsubstantiated at this time.

Exit interview conducted and report emailed to licensee.

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Darlene Chavez
LICENSING EVALUATOR SIGNATURE:	DATE: 04/09/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/09/2022

LIC9099 (FAS) - (06/04)

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