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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 435202124
Report Date: 04/11/2023
Date Signed: 04/11/2023 10:29:32 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/01/2022 and conducted by Evaluator David Marrufo
COMPLAINT CONTROL NUMBER: 26-AS-20220901111346
FACILITY NAME:BEYOND POTENTIAL LEARNING CENTERFACILITY NUMBER:
435202124
ADMINISTRATOR:CARMELA MAGPAYOFACILITY TYPE:
775
ADDRESS:1753 SOUTH MAIN STREETTELEPHONE:
(408) 438-0442
CITY:MILPITASSTATE: CAZIP CODE:
95035
CAPACITY:75CENSUS: 56DATE:
04/11/2023
UNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Melissa RamosTIME COMPLETED:
10:45 AM
ALLEGATION(S):
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Facility did not administer client's medications
Facility staff left client unsupervised in room
Facility staff restrained client in wheelchair
INVESTIGATION FINDINGS:
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On 04/11/2023, Licensing Program Analyst (LPA) David Marrufo conducted an unannounced inspection/investigation visit to conclude and deliver investigation of the above allegations. LPA Marrufo met with Melissa Ramos, Administrator/Program Director.

On 09/07/2022, the Department conducted a preliminary investigation of the above allegations. Copies of staff and residents' facility file documents were obtained. The following documents were obtained but not limited to client (C1's) Individual Program Plan (IPP), medication record, C1's information, LIC 9172, Functional Capability, Agreements and DDS assessment and staff information who had knowledge of the incident.


Page 1 of 3. See LIC9099-C for more information.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE:

DATE: 04/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2023
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 5
Control Number 26-AS-20220901111346
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME: BEYOND POTENTIAL LEARNING CENTER
FACILITY NUMBER: 435202124
VISIT DATE: 04/11/2023
NARRATIVE
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Based on staff interviews, Administrator (ADM) stated that on 08/29/22, ADM received a phone call from C1's RP to inform that C1 will not be attending the day program because C1's medication was not administered as a result C1 had seizure evening of 08/28/22. Administrator stated was not aware nor there was a report received that C1's medication bottle was not received nor it was not administered on 08/28/22 by the staff responsible or designated to assist C1 with medication.

Administrator conducted an in-house investigation with Staff (S1), C1's RP informed S1 of C1's medication in the bag during R1's dropped off on 08/28/2022. S1 subsequently informed another staff (S2) then S2 informed S3 about C1's medication. Furthermore, aside from the 3 staff (S1-S3), staff (S4) who checked C1's bag for lunch apparently saw C1's medication bottle but did not verify if medication was given either.

Based on staff interviews, Administrator (ADM) was informed that C1 was observed alone in a room unsupervised on 08/28/2022 by R1's RP. RP also stated that C1 was wearing a seat belt.

ADM stated an in-house investigation was conducted with staff who were involved. ADM stated staff assigned to disinfect the facility had decided to bring C1 in a room (designated as their sick room located across the facility kitchen) to prevent C1 from inhaling toxins produced by cleaning disinfectants during an end of the day facility sanitation. ADM stated that C1 was the only client left in the facility while waiting to be picked up by RP. ADM stated that staff (S4) was the designated staff to supervise C1 in the room. S4 left C1 for less than a minute for the office. S4 did not have a line-of-sight supervision of C1 from the office.

ADM stated that on 08/28/2022, staff brought clients including C1 for a walk. ADM stated that C1 did not have a steady gait, exhibits behaviors such as grabbing staff and clients, and being disruptive. Staff has decided to utilize wheelchair with a seat belt to prevent C1 from falling. ADM stated there was not a medical note for the use of seat belt.

Page 2. See continuation page for more information. Page 2 of 3.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE:

DATE: 04/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 26-AS-20220901111346
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME: BEYOND POTENTIAL LEARNING CENTER
FACILITY NUMBER: 435202124
VISIT DATE: 04/11/2023
NARRATIVE
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The Department has conducted an investigation on the complaint allegations. Based on records reviewed, and interviews conducted, the preponderance of evidence standard has been met. Therefore, the Department found that the above allegations are SUBSTANTIATED. Deficiencies are being cited. See LIC 9099-D.

This report was reviewed with Administrator/Program Director Melissa Ramos and a copy of the report and appeal rights were provided.

Page 3 of 3. END REPORT.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE:

DATE: 04/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 26-AS-20220901111346
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: BEYOND POTENTIAL LEARNING CENTER
FACILITY NUMBER: 435202124
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/11/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/12/2023
Section Cited
CCR
82075(b)
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Health Related Services: 82075(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. This requirement was not met as evidence by:

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Licensee agrees to submit a plan to train staff on assisting clients with self-administration of medications by POC date. Once the training is complete, the Licensee agrees to submit copies of the training records to CCLD. The training records should include date(s) of training and names of staff trained, and
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Staff designated to assist with C1's medication did not administer C1's seizure on 08/28/22. A review of medication record did not show medication was given, and as a result C1 had a seizure that evening, which posed an immediate risk to clients in care.
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name and qualifications of trainer(s).
Type A
04/12/2023
Section Cited
CCR
82072(a)(8)(B)
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Personal Rights 82072:(a)Each client shall have personal rights which include, but are not limited to, the following:(8) Not to be placed in any restraining device. Postural supports may be used under the following conditions: (B) A written order from the client's physician indicating the need for postural supports shall be maintained in the client's record.
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Licensee agrees to submit a plan to train staff on (1) client's personal rights to not be placed in any restraining device and (2) when postural supports may be used on a client by POC date. Once the training is complete, the Licensee agrees to submit copies of the training records to
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The licensing agency shall be authorized to require additional documentation if needed to verify the order. This requirement is not met as evidence by: C1 does not have an medical order for the seatbelt and staff S4 left client C1 unsupervised alone in a room in a wheelchair with seatbelt, which posed an immediate safety risk to clients in care.
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CCLD. The training records should include date(s) of training and names of staff trained, and name and qualifications of trainer(s).
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: Sarah Yip
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE:

DATE: 04/11/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5
Control Number 26-AS-20220901111346
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: BEYOND POTENTIAL LEARNING CENTER
FACILITY NUMBER: 435202124
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/11/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/12/2023
Section Cited
CCR
82078(a)
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Responsibility for Providing Care and Supervision 82078(a): The licensee shall provide care and supervision necessary to meet the client's needs and all services specified in the admission agreement.
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Licensee agrees to submit a plan to train staff on providing care and supervision necessary to meet the clients needs by POC date. Once the training is complete, the Licensee agrees to submit copies of the training records to CCLD.
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This requirement was not met as evidenced by: Staff S4 left client C1 unsupervised in a room beyond line-of-sight, which posed an immediate safety risk to clients in care.
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The training records should include date(s) of training and names of staff trained, and name and qualifications of trainer(s).
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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: Sarah Yip
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE:

DATE: 04/11/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 5