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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 455002730
Report Date: 06/14/2022
Date Signed: 06/14/2022 01:22:54 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/09/2022 and conducted by Evaluator Donna Gurriere
PUBLIC
COMPLAINT CONTROL NUMBER: 25-AS-20220209140549
FACILITY NAME:IPS- PICKFORD WAYFACILITY NUMBER:
455002730
ADMINISTRATOR:GARDNER, BONNIEFACILITY TYPE:
735
ADDRESS:20374 PICKFORD WAYTELEPHONE:
(530) 605-3605
CITY:REDDINGSTATE: CAZIP CODE:
96003
CAPACITY:4CENSUS: 4DATE:
06/14/2022
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Leana KenyonTIME COMPLETED:
11:15 AM
ALLEGATION(S):
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Knives left accessible to clients.
Facility is neglecting client’s needs.
INVESTIGATION FINDINGS:
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Donna Gurriere, Licensing Program Analyst was in contact and met with Leana Kenyon, Direct Support Staff. It was alleged that Staff did not prevent a resident from engaging in inappropriate behaviors and making inappropriate comments towards residents.

LPA Gurriere completed the required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID 19 infection to affirm no COVID-19 related symptoms. The administrator/staff person was contacted to complete a facility risk assessment. LPA Gurriere ensured that hand sanitizer was applied before entering the facility and the following Personal Protective Equipment (PPE) was worn: N-95 mask. Additionally, LPA Gurriere was screened by a staff person upon entering the facility.

continued
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Donna Gurriere
LICENSING EVALUATOR SIGNATURE:

DATE: 06/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2022
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 25-AS-20220209140549
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME: IPS- PICKFORD WAY
FACILITY NUMBER: 455002730
VISIT DATE: 06/14/2022
NARRATIVE
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Knives left accessible to clients.
During the investigative process, the administrator, regional center coordinator, six staff persons and the two residents involved were interviewed. In addition, various documents were obtained to include Physicians Reports, Individual Program Planning (IPP) and Admission Agreements.

During the interview process, it was reported that the resident (Resident 1) ripped the cupboard door off the cabinet, grabbed a knife and chased after a second resident (Resident 2). The knife was taken away; however, a second incident occurred in that resident 1 obtained the keys to the locked cabinet, opened the cabinet, grabbed a knife and chased after resident 2 a second time. The authorities were called and resident 1 was taken away on a “5150 hold” in that resident 1 was fully assessed for her mental health status.

Based on the evidence obtained, the preponderance of evidence standard has been met; therefore, the deficiency is found to be Substantiated. California Code of Regulations (Title 22) is being cited on the attached LIC 809D. Appeal rights were provided, and the exit interview conducted.

Facility is neglecting client’s needs.
During the investigative process, the administrator, regional center coordinator, six staff persons and the two residents involved were interviewed. In addition, various documents were obtained to include Physicians Reports, Individual Program Planning (IPP) and Admission Agreements.

During the interview process, it was reported that the two residents involved, Resident 1 and Resident 2 are both involved in engaging in inappropriate behaviors and comments to include, making threatening remarks, using foul language and name calling, chasing, and at times, pushing hitting, spitting, pinching, and punching staff. Emergency services (911) have been called several times. The personal rights of both residents are being violated.

continued
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Donna Gurriere
LICENSING EVALUATOR SIGNATURE:

DATE: 06/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 4
Control Number 25-AS-20220209140549
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME: IPS- PICKFORD WAY
FACILITY NUMBER: 455002730
VISIT DATE: 06/14/2022
NARRATIVE
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Based on the evidence obtained, the preponderance of evidence standard has been met; therefore, the deficiency is found to be Substantiated. California Code of Regulations (Title 22) is being cited on the attached LIC 809D. Appeal rights were provided, and the exit interview conducted.
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Donna Gurriere
LICENSING EVALUATOR SIGNATURE:

DATE: 06/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 25-AS-20220209140549
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: IPS- PICKFORD WAY
FACILITY NUMBER: 455002730
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/14/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/21/2022
Section Cited
CCR
80072(a)(3)
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Personal Rights 80072 - 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 daily living activities.
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The licensee agrees to give a 3-day notice of eviction to a resident and shall submit the eviction notice to the licensing agency within 7 days, 06/21/22.
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The licensee did not ensure that residents are free from personal rights violations.
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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: Anthony Perez
LICENSING EVALUATOR NAME: Donna Gurriere
LICENSING EVALUATOR SIGNATURE:

DATE: 06/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 4