486803728-8-17-2023-21-AS-KMOA-CV7NU4-20230830104543

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 486803728
Report Date: 08/17/2023
Date Signed: 08/17/2023 12:49:32 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, 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
06/15/2023 and conducted by Evaluator Dominic Tobola

COMPLAINT CONTROL NUMBER: 21-AS-20230615163724

FACILITY NAME:	PALM VIEW RETREAT		FACILITY NUMBER:	486803728
ADMINISTRATOR:	HARRIS, DAE'JANIQUE		FACILITY TYPE:	735
ADDRESS:	150 BROADWAY STREET		TELEPHONE:	(707) 652-2624
CITY:	VALLEJO	STATE: CA	ZIP CODE:	94590
CAPACITY:	32	CENSUS:	DATE:	08/17/2023
		UNANNOUNCED	TIME BEGAN:	10:29 AM
MET WITH:	Dae Harris, Administrator		TIME COMPLETED:	11:30 AM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff did not redirect clients in a verbal altercation, violating one clients personal rights
Buildings and grounds, facility restrooms are unsafe

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

On 8/17/2023 Licensing Program Analyst (LPA) Tobola arrived unannounced for the purpose of delivering complaint investigation findings and was greeted by Administrator, Dae Harris. LPA toured the facility, interviewed staff and clients, reviewed client records and made observations.

Complaint alleges staff did not redirect clients in a verbal altercation, violating one client’s personal rights. Based on interviews with clients (C1, C2 & C3), it was indicated that staff speak with clients directly, perform de-escalation techniques and redirection when clients engage in physical or verbal altercations with one another. In addition, based on interviews with staff (S1, S2 & S3) LPA found that staff were able to describe the appropriate use of redirection and de-escalation techniques when needed. Due to a lack of corroborating evidence the allegation is found to be unsubstantiated.

Continued onto LIC9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Dominic Tobola	TELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:	DATE: 08/17/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/17/2023

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-20230615163724

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: PALM VIEW RETREAT	FACILITY NUMBER: 486803728
	VISIT DATE: 08/17/2023

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

Complaint alleges the buildings and grounds facility restrooms are unsafe after client (C4) was reported to have slipped and become injured. Upon a review of unusual incident report dated 5/25/2023 LPA confirmed that client C4 was provided medical services due to a fall in the changing area within the shower room. Based on interviews with the Administrator, LPA was informed that on multiple occasions, clients have defecated on the shower mats which had to be removed for replacing or cleaning. Based on observations during two tours of the facility LPA found that shower rooms for client use were found to have been equipped with appropriate non-slip floor mats (photos taken). Although incident report indicates that C4 sustained a fall, there is no regulation under Title 22 for Adult Residential Facilities that require the facility to utilize non-slip mats within the shower. In addition, the incident involving C4 occurred while C4 was standing in the changing area of the shower room not directly in the shower. Due to contradicting information and Title 22 Regulation unable to support to the allegation, the allegation is found to be unsubstantiated.

Allegations, staff did not redirect clients in a verbal altercation, violating one clients personal rights and buildings and grounds, facility restrooms are unsafe are UNSUBSTANTIATED. A finding that the complaint is unsubstantiated means that although the allegations may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. Appeal Rights given.

No deficiencies cited during visit.

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Dominic Tobola	TELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:	DATE: 08/17/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/17/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 2