<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 486801782
Report Date: 11/20/2023
Date Signed: 11/27/2023 10:47:05 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/03/2023 and conducted by Evaluator Farhaan Sarangi
COMPLAINT CONTROL NUMBER: 21-AS-20231103161208
FACILITY NAME:CO-OPFACILITY NUMBER:
486801782
ADMINISTRATOR:SIMMONS, SAMIKAFACILITY TYPE:
775
ADDRESS:320 CERNON STREETTELEPHONE:
(707) 449-9377
CITY:VACAVILLESTATE: CAZIP CODE:
95688
CAPACITY:45CENSUS: 5DATE:
11/20/2023
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Floor Supervisor, Marcela Eduardo
Assistant
Assistant, Jacquelyn Barkum		TIME COMPLETED:
02:45 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not prevent a resident from assaulting another resident while in care
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
"AMENDED" This is an amended version of the original report created on November 20, 2023-SEE BELOW.

Licensing Program Analyst (LPA), Farhaan Sarangi arrived unannounced at CO-OP for the purpose of delivering complaint findings. LPA was greeted at the door by, Assistant, Jacquelyn Barkum and was granted access into the facility.

During the course of the investigation, LPA interviewed a client and staff members at the facility. In addition, LPA reviewed files for Client #1 and Client #2.

Complaint alleges that Staff did not prevent a resident from assaulting another resident while in care. During the opening of the complaint on Noveber 7, 2023, LPA reviewed Client #1 and Client #2’s file. LPA learned that Client #2’s Individual Program Plan (IPP) indicated that the client has a history of emotional outburst behavior which includes screaming and aggresion towards staff and client (Report continued on LIC 9099C)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE:

DATE: 11/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2023
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 4
Control Number 21-AS-20231103161208
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: CO-OP
FACILITY NUMBER: 486801782
VISIT DATE: 11/20/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
"AMENDED" This is an amended version of the original report created on November 20, 2023-SEE BELOW.

A review of Client #1's Individual Program Plan indicates that the client has emotional outburst behaviors. LPA conducted interviews with clients and staff, LPA learned that during the incident, both Client #1 and Client #2 were placed next to each other in the rear seats of the vehicle when Client #2 became aggressive and scratched Client #1. During interviews with Client #2, it was disclosed that two staff members were sitting up in the driver side front seat and passenger side front seat of the van and that no staff were present in the back of the van. While interviewing the Caregiver, LPA learned that the Caregiver and Driver were both sitting in the front seats of the van and no staff were present in the back of the van because it didn’t occur to her that she needed to watch both clients (See LIC 9099D). Furthermore, after the incident, Community Care Licensing was not notified of the fall incident and the client becoming physically aggressive towards another client (See LIC 809-Case Management-Other inspection dated for November 20, 2023). LPA educated the Floor Supervisor on Personal Rights as it relates to Personal Rights of clients in care.

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12-month period may result in civil penalties. Exit interview was conducted, and a copy of this report was signed and given to the Assistant.

SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE:

DATE: 11/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 21-AS-20231103161208
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: CO-OP
FACILITY NUMBER: 486801782
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/20/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
CCR
1
2
3
4
5
6
7
"AMENDED" This is an amended version of the original report created on November 20, 2023-SEE BELOW

NO CITATION ISSUED DUE TO AMENDED REPORT FINDINGS ON NOVEMBER 27, 2023.
1
2
3
4
5
6
7
8
9
10
11
12
13
14
8
9
10
11
12
13
14
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: Hope DeBenedetti
LICENSING EVALUATOR NAME: Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE:

DATE: 11/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 21-AS-20231103161208
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: CO-OP
FACILITY NUMBER: 486801782
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/20/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/21/2023
Section Cited
CCR
82072(a)(2)
1
2
3
4
5
6
7
82072(a)(2): Personal Rights

Each client shall have personal rights which include, but are not limited to, the following:

(2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs.

This requirement was not met as evidenced by:
1
2
3
4
5
6
7
POC: Licensee shall submit a an LIC 9098 understanding the regulation. Licensee shall submit a Plan for Future Compliance and how this plan will be implemented. Licensee shall retrain ALL staff that provide care to clients and provide proof of training to Licensing by November 21, 2023.
8
9
10
11
12
13
14
Based on interviews that were conducted with a client and staff, LPA learned that during the incident, Client #1 and Client #2 were placed next to each other in the rear seats of the vehicle when Client #2 became aggressive and scratched Client #1. During interviews with Client #2, it was disclosed that two staff members were sitting up in the driver side front seat and passenger side front seat of the van and that no staff were present in the back of the van. While interviewing the Caregiver, LPA learned that the Caregiver and Driver were both sitting in the front seats of the van and no staff were present in the back of the van because it didn’t occur to her that she needed to watch both clients. This incident presents an immediate Health, Safety and Personal Rights risk to the client(s) in care.
8
9
10
11
12
13
14
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: Hope DeBenedetti
LICENSING EVALUATOR NAME: Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE:

DATE: 11/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 4