496801932-9-6-2024-21-AS-VBEI-D93TX9-20240913150642

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 496801932
Report Date: 09/06/2024
Date Signed: 09/06/2024 10:42:42 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 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
06/21/2024 and conducted by Evaluator Christi Coppo

COMPLAINT CONTROL NUMBER: 21-AS-20240621164619

FACILITY NAME:	DUNGARVIN CALIFORNIA LLC		FACILITY NUMBER:	496801932
ADMINISTRATOR:	FAIRCHILD, CARRIE		FACILITY TYPE:	775
ADDRESS:	433-439 BEAVER ST		TELEPHONE:	(707) 543-5895
CITY:	SANTA ROSA	STATE: CA	ZIP CODE:	95404
CAPACITY:	75	CENSUS: 37	DATE:	09/06/2024
		UNANNOUNCED	TIME BEGAN:	10:03 AM
MET WITH:	Carrie Fairchild, Administrator		TIME COMPLETED:	10:57 AM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff did not prevent client from being harmed by another client

INVESTIGATION FINDINGS:

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

At approximately 10:00am, Licensing Program Analyst (LPA) Christi Coppo arrived unannounced to deliver findings regarding the above allegation and met with Carrie Fairchild, Administrator.
Complaint alleges staff did not prevent client from being harmed by another client. Complainant states that day program client C2 was punched in the face by day program client C1, both clients have developmental disabilities and Santa Rosa Police Department (SRPD) responded on 6/20/2024 (event#SR241720107).

During LPA investigation, LPA reviewed records and interviewed witnesses and staff. Witnesses and staff report that C1 typically was not violent towards others, but C1 would sometimes have a behavior of self-harm when experiencing bodily pain.

Continued on 9099C...

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Christi Coppo
LICENSING EVALUATOR SIGNATURE:	DATE: 09/06/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2024

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 2

Control Number 21-AS-20240621164619

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: DUNGARVIN CALIFORNIA LLC	FACILITY NUMBER: 496801932
	VISIT DATE: 09/06/2024

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

Continued from 9099...

LPA review of day program requirements indicate that clients must not have exhibited violent behavior for a least one year prior to being admitted to the day program, C1 met this criterion when admitted to program. LPA review of police report indicated that C1 was having an autistic episode and while punching in the air they turned and punched C2. Police report indicates C1 was discharged to their family and C2 was doing well. Police report indicated SRPD declined to report incident to Adult Protective Services.

On the day of the incident, witnesses report to CCL that C1 was engaging in unsafe behavior during an outing, by repeatedly removing their seat belt while traveling in the program van. As a result, C1 was not to have any computer time once back at the facility. This consequence frustrated C1. Once the van arrived back to the facility, C1 ran from the van to the computer room where S2 was present. S1 was present just outside the computer room in the hall, immediately after escorting the other clients that were in the van safely into facility. C1 was agitated and both S1 and S2 started de-escalation techniques. C1 moved past S2 through the doorway and entered the hallway. C1 proceeded to have an episode of punching in the air and jumping. As C1 was moving down the hall, still punching the air, C1 accidentally punched C2 in the face. C2 had been standing in the hallway a bit down from where C1 was punching the air. As C1 ran down the hall, they made contact with C2. The punch was not directed at C2. Staff were still actively trying to de-escalate C1. Staff were engaged with and attending to C1 during the incident. LPA review of records show staff received de-escalation training. De-escalation is relational based at facility, staff do not use PRO-ACT or other restraints on clients. So, although the allegation 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.

SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Christi Coppo
LICENSING EVALUATOR SIGNATURE:	DATE: 09/06/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 2