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

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 486801782
Report Date: 12/12/2023
Date Signed: 12/12/2023 12:22:17 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, 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
12/01/2023 and conducted by Evaluator David Leibert
COMPLAINT CONTROL NUMBER: 21-AS-20231201140950
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: 17DATE:
12/12/2023
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Jacquelyn BarkumTIME COMPLETED:
12:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not notify responsible party of client injury sustained while in care.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst Leibert arrives unannounced for the purpose of delivering findings on this complaint. C1 fell on or about 10/26/2023 and sustained injury which included fracture to 2 teeth and cut to lower lip which bleed. Staff applied first aid, notified the Administrator, and transported C1 home. Transportation staff notified C1's Responsible Person of the accident when C1 returned home. Responsible Person and Administrator spoke via phone about the incident approximately 1 and 1/2 hours after the accident. Facility's Plan of Operation requires a written notification be made within 24 hours to the Responsible Person if a client receives an injury while at Program. As of 12/01/2023, no written notification has been made by facility to Responsible Person. Based upon the documents and photographs reviewed, as well as statements from the Administrator and staff, the preponderance of evidence standard has been met. Therefore, the allegation is SUBSTANTIATED. The following deficiencies were observed (see LIC 9099D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided.

Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Carla Martinez
LICENSING EVALUATOR NAME: David Leibert
LICENSING EVALUATOR SIGNATURE:

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

DATE: 12/12/2023
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 21-AS-20231201140950
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: 12/12/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/22/2023
Section Cited
CCR
82022(h)
1
2
3
4
5
6
7
82022(h) Plan of Operation. The day program shall operate in accordance with the terms specified in the plan of operation and may be cited for not doing so. *** Based upon statements made, documents reviewed, this requirement has not been met as evidenced by: C1
1
2
3
4
5
6
7
Administration to review facility’s Program Plan and submit a writen plan on how the reporting requirements will be met going forward. Plan to be submited to CCL by POC date in order to clear the deficiency
8
9
10
11
12
13
14
received an injury at Program on 10/26/2023 and no written report was made to the Responsible Person. This a potential risk to the personal rights of C1.
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: Carla Martinez
LICENSING EVALUATOR NAME: David Leibert
LICENSING EVALUATOR SIGNATURE:

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

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