435202592-1-4-2023-26-AS-KHOS-CP5KWS-20230217071625

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202592
Report Date: 01/04/2023
Date Signed: 01/04/2023 03:54:47 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, 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
09/16/2022 and conducted by Evaluator Chihhsien Chang

COMPLAINT CONTROL NUMBER: 26-AS-20220916130849

FACILITY NAME:	FOOTHILL ADULT RESIDENTIAL FACILITY		FACILITY NUMBER:	435202592
ADMINISTRATOR:	ANGELICA ATRIANO		FACILITY TYPE:	735
ADDRESS:	13655 FOOTHILL AVE		TELEPHONE:	(669) 231-3861
CITY:	SAN MARTIN	STATE: CA	ZIP CODE:	95046
CAPACITY:	4	CENSUS: 3	DATE:	01/04/2023
		UNANNOUNCED	TIME BEGAN:	09:20 AM
MET WITH:	Bonnie Jiracek Codd		TIME COMPLETED:	10:00 AM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Resident sustained multiple injuries due to lack of supervision/neglect.
Resident was not accorded a safe accommodation to meet his needs.
Resident's records was incomplete.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Steve Chang conducted an unannounced complaint investigation visit to deliver the investigation findings and met with House Manager (HM) Bonnie Jiracek Codd.

On 09/16/2022, the Department received a complaint with the above 3 allegations.

On 9/20/2022, an initial investigation visit was conducted. LPA met with ADM and House Manager (HM) Bonnie Jiracek Codd. Client roster, staff roster, staff schedules, client files, staff notes, incident reports. and staff files were obtained. On 12/29/22, LPA obtained records of R1's file.

From 10/10/2022 to 12/29/2022, the Department interviewed 6 staff including Administrator (ADM) and 3 residents (R2 - R4).

Continued on LIC9099-C. Page 1 of 3.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:	DATE: 01/04/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/04/2023

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 3

Control Number 26-AS-20220916130849

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: FOOTHILL ADULT RESIDENTIAL FACILITY	FACILITY NUMBER: 435202592
	VISIT DATE: 01/04/2023

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Resident sustained multiple injuries due to lack of supervision/neglect:
R1 was assigned a 1:1 direct care staff for 8 hours a day according to R1’s Individual Program Plan (IPP). R1 was never left unsupervised in the facility unless R1 asked for privacy or space. Facility staff provide a safe environment and respect the wishes of their clients. The facility staff do not bother or check the clients unless absolutely necessary or when requested by the client themselves. On 9/15/2022, R1 asked for privacy and went into R1's room. Around 5 minutes later, R1 exited R1's room and asked staff for help. R1 inserted a colored pencil into R1's private area. The facility called 911 and sent R1 to hospital immediately. Staff were aware of R1’s history of inserting objects into R1’s private area and had made arrangement for items to be stored and locked away. After the incident, the facility brainstormed ideas on how to keep R1 safe. The facility agreed to store crayons, color pencils and other writing instruments out of R1’s reach and monitor it closely. ADM pushed for additional 1:1 funding for R1, and increased staffing at the facility to account for R1’s behaviors and other residents in care.

Resident was not accorded a safe accommodation to meet his needs:
On 10/10/2022, the Department interviewed 5 staff members and ADM. R1 has maladaptive behaviors that continues to escalate while at the facility because R1 has learned to push boundaries while staff re-direct R1 and provide other options. R1 refused to listen to staff directives and did what R1 wanted. 5 out of 5 staff stated that if an incident occurs with the residents, the staff redirect the resident and try to de-escalate the behavior. All staff and ADM stated they document the residents throughout the day, such as their behaviors, ADLs, all cleaning, chores completed, and activities completed. ADM stated if an incident occurs, the Ukeru pads are used when residents are escalating. If a resident sustained an injury that is beyond first aid, the residents are taken to the emergency department (ED). If residents ask to be taken to the ED, staff will either bring them or call the ambulance to transport them. One staff stated residents are checked every 30 – 60 minutes and another staff stated during NOC shift, residents are supposed to be checked on three times during the night, and when the facility door is open, and a loud beeping sound is made.

On 10/10/2022, the Department interviewed 3 residents (R2 - R4). 2 out of 2 residents stated they felt safe living at the facility and one resident did not state whether they felt safe living at the facility; however, the resident stated it was awesome to live in the facility.

Continued on LIC9099-C. Page 2 of 3.

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:	DATE: 01/04/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/04/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 26-AS-20220916130849

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: FOOTHILL ADULT RESIDENTIAL FACILITY	FACILITY NUMBER: 435202592
	VISIT DATE: 01/04/2023

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Resident's records was incomplete:
R1 was admitted to the facility on 09/01/2022. At the time of the incident, R1 has been at the facility for less than 30 days. At the time of the incident, R1 had the following documents: IPP, Transition Planning meeting document, San Andreas Regional Center Summary Turnaround -- Confidential Client W & I code SEC. 4514, Service Requested document the facility provided to Service Coordinator of SARC, Physician Report dated 8/30/2022, Dental Report dated 8/18/2022, Client Development Evaluation Report from SARC dated 8/6/2021, Appraisal /Needs and Service Plan Dated 8/25/2022, Statement of Risk and Reasonable Precaution from corporation Clinical Department, Porterville Development Center IPP, Behavior Support Plan. name the documents) in R1’s file.

On 12/29/2022, LPA interviewed ADM and conducted facility file reviews. 4 current residents and 1 prior resident facility files were reviewed. R4's files did not have a physician report and R1's files did not have TB (Tuberculosis) information. Both R1 and R4 have been in the facility less than 30 days.

The department has investigated the above allegations. Based on the investigation, observations, records reviewed, and interviews conducted, the Department found that the above allegations are UNSUBSTANTIATED. An unsubstantiated finding indicates that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the allegations did or did not occur.

No citations noted at today’s complaint investigation visit. Exit interview was conducted with HM. A copy of this report was provided to HM.

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:	DATE: 01/04/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/04/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 3