425850083-3-7-2024-29-AS-KBUY-D3TUYC-20240329155944

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 425850083
Report Date: 03/07/2024
Date Signed: 03/07/2024 11:36:43 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
02/28/2024 and conducted by Evaluator Mark Jeffries

COMPLAINT CONTROL NUMBER: 29-AS-20240228112520

FACILITY NAME:	DOCTOR'S RESIDENTIAL CARE FACILITY #2		FACILITY NUMBER:	425850083
ADMINISTRATOR:	GILL, NATASHA		FACILITY TYPE:	735
ADDRESS:	2412 CESAR E CHAVEZ DR		TELEPHONE:	(702) 858-4266
CITY:	SANTA MARIA	STATE: CA	ZIP CODE:	93458
CAPACITY:	4	CENSUS: 4	DATE:	03/07/2024
		UNANNOUNCED	TIME BEGAN:	08:38 AM
MET WITH:	Administrator, Natasha Gill		TIME COMPLETED:	10:49 AM

ALLEGATION(S):

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Staff hit resident.

INVESTIGATION FINDINGS:

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At 9:00am on 03/07/2024, Licensing Program Analyst (LPA) Jeffries arrived unannouced to the facility to issue final findings to the allegations of this complaint. LPA met with Adminstrator, Natasha Gill, announced who he is and the reason for the visit.

As to the allegation of, “Staff hit resident.” It was alleged that, on 02/26/2024 at approximately 8pm, Staff 1 (S1) hit Resident 1 (R1) causing R1 to fall and hit head causing stiches to R1. It was discovered through interviews, on 03/01/2024, with R1, where R1 stated that during an argument between R1 and S1, that S1 touched R1’s shoulder. R1 stated that, it was not a hit, it was a touch, like a “nudge” according to R1. R1 stated that at no time was R1 in pain and R1 did not think that the “nudge” was meant to hurt R1. R1 stated that S1 had never caused him any pain. When R1 was asked about the stiches in R1’s head that they had reported, R1 stated that S1 hit R1 that caused S1 to fall, hit their head on the wall causing stiches. It was discovered through interviews on 03/01/2024 of facility Administrator,
CONTINUED on LIC9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Mark Jeffries	TELEPHONE: (805)562-0400
LICENSING EVALUATOR SIGNATURE:	DATE: 03/06/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/06/2024

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-20240228112520

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: DOCTOR'S RESIDENTIAL CARE FACILITY #2	FACILITY NUMBER: 425850083
	VISIT DATE: 03/07/2024

NARRATIVE

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S1, and S2 that R1 had not been to the Emergency Room, Urgent Care, or seen by a medical professional any time after this incident nor did R1 request to be evaluated of any injury. In an interview with S1 on 03/01/2024, S1 stated that they (S1) did raise their voice with R1 but denies that they had ever touched R1 on the shoulder. S1 stated that R1 did try and lunge at S1 and S1 moved out of the way of R1. Interview of S2 on 03/01/2024, S2 stated they did not see any physical altercations between S1 and R1 but there was yelling between the two. Based on interviews, lack of medical visit, and admission, at this time, there is not enough evidence to support the allegation of, “Staff hit resident.” and is unsubstantiated at this time.

Exit interview, report read, and report provided.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Mark Jeffries	TELEPHONE: (805)562-0400
LICENSING EVALUATOR SIGNATURE:	DATE: 03/06/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/06/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 4

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
02/28/2024 and conducted by Evaluator Mark Jeffries

COMPLAINT CONTROL NUMBER: 29-AS-20240228112520

FACILITY NAME:	DOCTOR'S RESIDENTIAL CARE FACILITY #2		FACILITY NUMBER:	425850083
ADMINISTRATOR:	GILL, NATASHA		FACILITY TYPE:	735
ADDRESS:	2412 CESAR E CHAVEZ DR		TELEPHONE:	(702) 858-4266
CITY:	SANTA MARIA	STATE: CA	ZIP CODE:	93458
CAPACITY:	4	CENSUS: 4	DATE:	03/07/2024
		UNANNOUNCED	TIME BEGAN:	08:38 AM
MET WITH:	Administrator, Natasha Gill		TIME COMPLETED:	10:49 AM

ALLEGATION(S):

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Staff handled resident roughly.

INVESTIGATION FINDINGS:

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As to the allegation of, “Staff handled resident roughly.” It was alleged that on 02/26/2024 that S1 handled R1 roughly. It was discovered through interviews on 03/01/2024 of R1 that R1 and S1 were arguing with each other on 02/26/2024 at approximately 8pm, about headphone volume and bedtime. In interviews on 03/01/2024 with S1, S1 stated that they did get into an argument with R1 on 02/26/2024 at approximately 8pm. S1 also stated that “I lost it momentarily” regarding the argument and yelled at R1. On 02/28/2024, LPA reviewed an audio recording of the incident on 02/26/2024 obtained by Reporting Party (RP), where evidence of an argument was clear that S1 was involved with an argument with R1 at elevated decibel, and in an inappropriate manor which could be characterized as “rough”. In an interview with R1 0n 03/01/2024, R1 stated that R1 and S1 were yelling at each other over headphones and going to bed. Based on admission, recording, documentation, and interviews there is enough evidence at this time to conclude that the allegation of, “Staff handled resident roughly.” and is substantiated at this time.
Exit interview, report read, citation issued, appeal rights, and report provided.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Mark Jeffries	TELEPHONE: (805)562-0400
LICENSING EVALUATOR SIGNATURE:	DATE: 03/06/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/06/2024

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

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 29-AS-20240228112520

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: DOCTOR'S RESIDENTIAL CARE FACILITY #2	FACILITY NUMBER: 425850083
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/07/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 03/21/2024 Section Cited CCR 80072(a)(1)	1 2 3 4 5 6 7	80072 Personal Rights (a)Except for children’s residential facilities, each client shall have personal rights which include, but are not limited to, the following: (1) To be accorded dignity in his/her personal relationships with staff and other persons. This requirement was not met by	1 2 3 4 5 6 7	Licensee agrees to provide resident personal rights training of 1 hour, and resident in crisis de-escalation training of 1 hour, and holding skills componet of CPI for all Staff 1 to be completed with-in two weeks of this report. The training must be CPI State Vendor approved training. Evidence of training
	8 9 10 11 12 13 14	evidence of S1 yelling at R1, which poses a potential danger to residents in care.	8 9 10 11 12 13 14	and completion of training can be emailed to LPA (mark.jeffries@dss.ca.gov)
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
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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.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Mark Jeffries	TELEPHONE: (805)562-0400
LICENSING EVALUATOR SIGNATURE:	DATE: 03/06/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/06/2024

LIC9099 (FAS) - (06/04)

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