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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 455002046
Report Date: 08/27/2024
Date Signed: 08/27/2024 02:27:17 PM

Document Has Been Signed on 08/27/2024 02:27 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:PEREGRINE HOMEFACILITY NUMBER:
455002046
ADMINISTRATOR/
DIRECTOR:		BRANSCOMB, KALEBFACILITY TYPE:
735
ADDRESS:1163 PEREGRINE WAYTELEPHONE:
(530) 262-0967
CITY:REDDINGSTATE: CAZIP CODE:
96003
CAPACITY: 4CENSUS: 4DATE:
08/27/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:45 PM
MET WITH:Direct Care Provider Tanya FranzkowiakTIME VISIT/
INSPECTION COMPLETED:
02:30 PM
NARRATIVE
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On August 27, 2024, at approximately 1:45 PM, Licensing Program Analyst (LPA), Farhaan Sarangi arrived unannounced at Peregrine Home for the purpose of conducting a Case Management-Deficiencies
inspection. LPA was greeted at the door by Direct Care Provider Tanya Franzkowiak, and was granted access into the facility. Administrator, Kaleb Branscomb arrived 20 minutes later.

During the course of the Case Management-Deficiencies inspection, LPA reviewed client records, interviewed clients in care and staff. In addition, LPA made client observations on July 22, 2024, and observed no bruises, marks, or scratches.

During this Case Management-Deficiencies inspection, LPA learned via an interview with Direct Care Staff Member #2 that Direct Care Staff Member #1 was observed dragging a client by the feet to the bedroom. During questioning, Direct Care Staff Member #2 did not recall the date or time that this happened but did observe the Direct Care Staff Member #1 drag the client by the feet to the bedroom. LPA conducted an interview with Direct Care Staff Member #3 and learned that Direct Care Staff Member #3 assisted Direct Care Staff Member #1 in dragging the client to the bedroom by the feet. During an interview with Direct Care Staff Member #1, LPA learned that the client in question fell on the floor and was “scooted” to the bedroom. On July 31, 2024, LPA received an email from the Administrator with Termination Documents that depicted both Direct Care Staff Member #1 and #3 were terminated from the facility after the incident (See LIC 9099D).

Deficiencies cited from the California Code of Regulations, Title 22, Division 6, Chapter 6 of California Regulation. Appeal rights were provided. Failure to correct the deficiency and/or repeat deficiencies within a 12-month period may result in additional civil penalties. Exit interview was conducted, and a copy of this report was signed and given to the Administrator.
SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE: DATE: 08/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/27/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/27/2024 02:27 PM - It Cannot Be Edited


Created By: Farhaan Sarangi On 08/27/2024 at 02:08 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: PEREGRINE HOME
FACILITY NUMBER: 455002046

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/27/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/28/2024
Section Cited
CCR
80072(a)(3)

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80072(a)(3) Personal Rights

(a) Except for children’s residential facilities, each client shall have personal rights which include, but are not limited to, the following:
(3) To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse, or other actions of a punitive nature, including but not limited to: interference with the daily living functions, including eating, sleeping, or toileting; or withholding of shelter, clothing, medication or aids to physical functioning.

This requirement was not met as evidenced by:
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Licensee shall submit an LIC 9098 understanding of the regulation. Furthermore, Licensee shall conduct staff training on Personal Rights and provide a statement on how future compliance will be met.
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Based on interviews that were conducted, LPA received consistent statements as it relates to Direct Care Staff Member #1 and #3 dragging the client by the feet to the bedroom which is an immediate health, safety, and personal rights risk to the clients in care.
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POC due date: September 02, 2024

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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:Lauren Crocker
LICENSING EVALUATOR NAME:Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE:
DATE: 08/27/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/27/2024


LIC809 (FAS) - (06/04)
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