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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 455002731
Report Date: 08/28/2024
Date Signed: 08/28/2024 12:48:28 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
06/26/2024 and conducted by Evaluator Farhaan Sarangi
COMPLAINT CONTROL NUMBER: 59-AS-20240626112126
FACILITY NAME:IPS- VINSON DRIVEFACILITY NUMBER:
455002731
ADMINISTRATOR:KNIGHT, JOSHUAFACILITY TYPE:
735
ADDRESS:1786 VINSON DRIVETELEPHONE:
(530) 605-3755
CITY:REDDINGSTATE: CAZIP CODE:
96003
CAPACITY:4CENSUS: 4DATE:
08/28/2024
UNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Administrator, Laura OlsonTIME COMPLETED:
01:00 PM
ALLEGATION(S):
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Due to lack of supervision, resident was able to leave the facility without staff knowledge
INVESTIGATION FINDINGS:
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On August 28, 2024, at approximately 11:45 AM, Licensing Program Analyst (LPA), Farhaan Sarangi arrived unannounced at IPS-Vinson Drive for the purpose of delivering complaint findings. LPA was greeted outside the door by Administrator, Laura Olson, and was granted access into the facility.

During the course of the investigation, LPA reviewed client records, interviewed clients in care, staff and a witness. In addition, LPA made client observations and toured the facility on July 22, 2024.

Complaint alleges Due to lack of supervision, resident was able to leave the facility without staff knowledge. Based on a review of the LIC 602, LPA learned that the client is not able to leave the facility unassisted. During the incident in question, client left that evening out of another client’s door. In addition, a review of the clients Service Plan under “Supervision Guidelines” indicates that staff will shadow the client and maintain supervision of the client (See LIC 9099D). (Report continued on LIC 9099C)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE:

DATE: 08/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2024
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 59-AS-20240626112126
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: IPS- VINSON DRIVE
FACILITY NUMBER: 455002731
VISIT DATE: 08/28/2024
NARRATIVE
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During an interview on July 18, 2024, at approximately 10:00 AM, LPA learned that when the incident occurred, the Administrator came right away to look for the client around the neighborhood. During an email conversation with the Regional Center placement agency, LPA learned that there has been a request for additional staffing that the Regional Center will be funding. LPA attempted to get additional clarifying information from the Regional Center placement agency but was unsuccessful.

Deficiencies cited from the California Code of Regulations, Title 22, Division 6, Chapter 1 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 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: 08/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 59-AS-20240626112126
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: IPS- VINSON DRIVE
FACILITY NUMBER: 455002731
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/28/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/29/2024
Section Cited
CCR
80078(a)(1)
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80078(a) Responsibility for Providing Care and Supervision

(a) The licensee shall provide care and supervision as necessary to meet the client's needs.

This requirement was not met as evidenced by:
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Licensee shall ensure that the facility is providing the Care and Supervision as outlined in Title 22 regulations. Furthermore, Licensee shall conduct staff training, submit an LIC 9098 and provide a statement on how future compliance will be met.
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Based on a record review of the clients LIC 602, the Client is not able to leave the facility unassisted. During the incident in question, the client left the facility unassisted and was out in the community which presents an immediate health, safety and personal rights risk to the client(s) in care.
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POC Due date: September 3, 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.
SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE:

DATE: 08/28/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3