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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 455002607
Report Date: 12/06/2023
Date Signed: 12/06/2023 04:49:12 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/04/2023 and conducted by Evaluator Kerry Hiratsuka
COMPLAINT CONTROL NUMBER: 59-AS-20231204164501
FACILITY NAME:COLLYER HOMEFACILITY NUMBER:
455002607
ADMINISTRATOR:VICTORINE, CHAYLENEFACILITY TYPE:
735
ADDRESS:699 COLLYER DRTELEPHONE:
(530) 244-7513
CITY:REDDINGSTATE: CAZIP CODE:
96003
CAPACITY:4CENSUS: 4DATE:
12/06/2023
UNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH: Chaylene Victorine TIME COMPLETED:
05:00 PM
ALLEGATION(S):
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Staff handled a resident inappropriately.
INVESTIGATION FINDINGS:
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LPA Hiratsuka conducted this unannounced complaint visit.

LPA interviewed staff and residents. Interviews confirmed Staff (S1) put a resident into a transport van to prevent the resident from lashing out at others but did not handle the situation appropriately. S1 does not have any training on physical restraints.

Based on the evidence obtained, the preponderance of evidence standard has been met; therefore, the allegation is found to be Substantiated. California Code of Regulations (Title 22) is being cited on the attached LIC 9099D.
Appeal rights are provided, and a closure interview was conducted.

Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Kerry Hiratsuka
LICENSING EVALUATOR SIGNATURE:

DATE: 12/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2023
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 2
Control Number 59-AS-20231204164501
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: COLLYER HOME
FACILITY NUMBER: 455002607
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/06/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/07/2023
Section Cited
CCR
80072(a)(1)
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Personal Rights. Except for children’s residential facilities, each client shall have personal rights which include, but are not limited to, the following: To be accorded dignity in his/her personal relationships with staff and other persons.
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By 12/07/2023, the licensee shall submit a written plan of correction stating what they shall do to prevent situations from occuring in the future. Administrator stated she is going to have meetings and look into more training.
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This requirement was not met as evidenced based by; upon records reviewed and interviews, S1 put R1 in a van and did not have restraint training. This poses an immediate health and safety risk to residents in care.
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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: Troy Ordonez
LICENSING EVALUATOR NAME: Kerry Hiratsuka
LICENSING EVALUATOR SIGNATURE:

DATE: 12/06/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2