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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 01:21:15 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, 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
02/11/2022 and conducted by Evaluator Donna Gurriere
COMPLAINT CONTROL NUMBER: 25-AS-20220211105904
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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A resident sustained injuries while in care and Facility tables are in disrepair.
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 A resident sustained injuries while in care and Facility tables are in disrepair.

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
Unsubstantiated
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 2
Control Number 25-AS-20220211105904
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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A resident sustained injury while in care.
During the investigative process, the administrator, regional center coordinator, six staff persons and two residents were interviewed. In addition, various documents were obtained to include Physicians Reports, Individual Program Planning (IPP) and Admission Agreements.

During the interview process, numerous staff persons reported that a resident (Resident 3) may have suffered an injury. It was stated that no one had any knowledge of resident 3 suffering an injury. Although the allegation may have happened, or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred, and the findings are Unsubstantiated.

Facility tables are in disrepair.
During the investigative process, the administrator, regional center coordinator, six staff persons and two residents were interviewed. In addition, various documents were obtained to include Physicians Reports, Individual Program Planning (IPP) and Admission Agreements.

During the interview process, numerous staff persons reported that although tables have been broken, they have not been left in the facility, in disrepair. It was reported that the tables have been thrown out in the trash and have been replaced, as needed. Although the allegation may have happened, or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred, and the findings are Unsubstantiated.
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)
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