486803802-10-20-2022-21-AS-CMAZ-CLAT2X-20221118132124

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 486803802
Report Date: 10/20/2022
Date Signed: 10/20/2022 02:18:41 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
05/04/2022 and conducted by Evaluator Katrina Walters

COMPLAINT CONTROL NUMBER: 21-AS-20220504141634

FACILITY NAME:	NORTH STAR #1		FACILITY NUMBER:	486803802
ADMINISTRATOR:	HICKS, JACQUELINE		FACILITY TYPE:	738
ADDRESS:	5939 PLEASANTS VALLEY RD		TELEPHONE:	(707) 452-0592
CITY:	VACAVILLE	STATE: CA	ZIP CODE:	95688
CAPACITY:	5	CENSUS: 3	DATE:	10/20/2022
		UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Jacquline Hicks		TIME COMPLETED:	02:35 PM

ALLEGATION(S):

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Staff failed to protect client,resulting in injury
Staff handled client in a rough manner

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA), Katrina Walters arrived unannounced at North Star 1 facility for the purpose of delivering complaint findings. LPA was greeted at the door by Program Director, Amelia Bao, and was granted access into the facility. Administrator, Jaqueline Hicks arrived later.

The Department received a complaint on 05/04/2022 that Staff failed to protect client, resulting in injury and that staff handled client in a rough manner. During the course of the investigation of the allegations LPA interviewed staff, reviewed incident reports, client records and charting notes. In addition LPA reviewed the facilities training to protect resident during Self Injurious behavior (SIB).

Continued on LIC 9099 C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Katrina Walters
LICENSING EVALUATOR SIGNATURE:	DATE: 10/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 21-AS-20220504141634

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: NORTH STAR #1	FACILITY NUMBER: 486803802
	VISIT DATE: 10/20/2022

NARRATIVE

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The complainant alleges that staff failed to protect client resulting injury and that that staff handled client in a rough manner. Records and statements from staff confirm that an incident occurred in which client C1 was having SIB that resulted in an injury. Staff used methods in their training to de-escalate the behavior and shield the client from injury, however injuries still occurred. Records also reveal that after the incident occurred staff seeked medical attention. Records indicate that Staff have received training on how to protect residents from SIB's. Additionally, interviews with staff did not corroborate the allegation that client was handled in a rough manner. Therefore LPA was unable to prove or disprove the allegations.

A finding that the allegations Staff failed to protect client, resulting in injury and Staff handled client in a rough manner are unsubstantiated meaning that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview was conducted and a copy of this was report was signed and emailed to Administrator due to printing issues.

SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Katrina Walters
LICENSING EVALUATOR SIGNATURE:	DATE: 10/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2022

LIC9099 (FAS) - (06/04)

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