525002436-3-21-2023-25-AS-KHOS-CQKNF5-20230404102458

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 525002436
Report Date: 03/21/2023
Date Signed: 03/21/2023 12:57:58 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833

This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/19/2022 and conducted by Evaluator Rebecca Knight

COMPLAINT CONTROL NUMBER: 25-AS-20221219151618

FACILITY NAME:	NORTH VALLEY SERVICES - RAWSON HOME		FACILITY NUMBER:	525002436
ADMINISTRATOR:	BURNHAM, CATHERINE		FACILITY TYPE:	735
ADDRESS:	10770 RAWSON RD		TELEPHONE:	(530) 527-7987
CITY:	RED BLUFF	STATE: CA	ZIP CODE:	96080
CAPACITY:	4	CENSUS:	DATE:	03/21/2023
		UNANNOUNCED	TIME BEGAN:	12:15 PM
MET WITH:	Eric Fulk - administrator		TIME COMPLETED:	01:00 PM

ALLEGATION(S):

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Physical abuse - SUBSTANTIATED
Staff are inappropriate towards client - SUBSTANTIATED

INVESTIGATION FINDINGS:

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03/21/2023 12:30 PM Licensing Program Analyst (LPA) Rebecca Knight, made an unannounced visit to the facility and met with administrator Eric Fulk. The purpose of this visit was to deliver the results of a complaint investigation. Prior to initiating the visit, LPA completed a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N95 mask, gloves.
During the course of the investigation the administrator, 3 clients, and 7 staff were interviewed. LPA requested and reviewed the following documents: related incident reports, LIC602, IPP, ISP, and Admission Agreements, staff list with telephone numbers, client list, internal investigation report.

Continued on LIC9099-C

Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Rebecca Knight
LICENSING EVALUATOR SIGNATURE:	DATE: 03/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2023

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 25-AS-20221219151618

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833

FACILITY NAME: NORTH VALLEY SERVICES - RAWSON HOME	FACILITY NUMBER: 525002436
	VISIT DATE: 03/21/2023

NARRATIVE

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Physical abuse - SUBSTANTIATED

LPA reviewed an internal investigation report pertaining to an incident that occurred on January 3, 2023 in which Staff 1 (S1) rushed, and shoved Client 1 (C1). This allegation was substantiated during the internal investigation at which time S1 was fired from employment with North Valley Services.

2 of 3 clients stated that C1 had been pushed down by facility staff.

1 of 7 staff stated that S1 had shoved C1, 1 of 7 staff stated that S1 had gotten aggressive with C1.

Based on interviews and document review it was determined that S1 shoved C1.This allegation is substantiated.

Continued on LIC9099-C

SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Rebecca Knight
LICENSING EVALUATOR SIGNATURE:	DATE: 03/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 25-AS-20221219151618

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833

FACILITY NAME: NORTH VALLEY SERVICES - RAWSON HOME	FACILITY NUMBER: 525002436
	VISIT DATE: 03/21/2023

NARRATIVE

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Staff are inappropriate towards client - SUBSTANTIATED

LPA reviewed an internal investigation report pertaining to an incident that occurred on January 5, 2023 in which S1 called C1 racial slur. This allegation was substantiated during the internal investigation at which time S1 was fired from employment with North Valley Services.

2 of 3 clients stated that S1 had called C1 a racial slur.

1 of 6 staff stated that S1 had called C1 a racial slur.

Based on interviews and document review it was determined that S1 called C1 a racial slur. This allegation is substantiated.

Based on evidence obtained during the investigation, the preponderance of evidence standard has been met, therefore, the above allegations are found to be SUBSTANTIATED. California Code of Regulations, (Title 22), is being cited on the attached LIC9099D. Appeal rights were provided.

The following deficiencies were observed (see LIC 9099D) and cited from the California Code of Regulations, Title 22, and California Health and Safety Code. This incident is currently under review and a future civil penalty may apply based on 1569.49(f) H&S. Failure to correct the deficiencies may also result in civil penalties.

Exit interview was conducted and the report was provided to administrator Eric Fulk.

SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Rebecca Knight
LICENSING EVALUATOR SIGNATURE:	DATE: 03/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 25-AS-20221219151618

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833

FACILITY NAME: NORTH VALLEY SERVICES - RAWSON HOME	FACILITY NUMBER: 525002436
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/21/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 04/04/2023 Section Cited CCR 80072(a)(3)	1 2 3 4 5 6 7	80072(a)(3) Personal Rights- Each client shall have personal rights which include, but are not limited to, the following: To be free from corporal or unusual punishment, infliction of pain, humiliation, ridicule, coercion, threat, mental abuse or other actions of a punitive nature. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Licensee agrees to provide training for all direct care and administrative staff on the personal right of clients to be free from corporal punishment. Licensee will schedule the training and provide CCL with the training content and signed staff attendance sheet as proof of correction. Additionally, Staff 1 was removed from the facility on January 6, 2023 and fired from employment with North Valley Services on January 13, 2023.
	8 9 10 11 12 13 14	Based on interviews and document review the licensee failed to ensure one of four clients (C1) was free from physical abuse when S1 shoved C1.This poses an immediate risk to clients in care.	8 9 10 11 12 13 14	The proof of correction is to be received by LPA Knight by 04/04/2023.
Type B 04/04/2023 Section Cited CCR 80072(a)(1)	1 2 3 4 5 6 7	80072(a)(1) Personal rights - (a) Except for children’s residential facilities, each client shall have personal rights which include, but are not limited to, the following: (1) To be accorded dignity in his/her personal relationships with staff and other persons. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Licensee agrees to provide training for all direct care and administrative staff on the personal right of clients to be accorded dignity in their relationship with staff. This training should have an emphasis on cultural diversity and sensitivity. Licensee will schedule the training and provide CCL with the training content and signed staff attendance sheet as proof of correction.
	8 9 10 11 12 13 14	Based on interviews and document review the licensee failed to ensure one of four clients (C1) was accorded dignity in their personal relationship with staff when S1 called C1 a racial slur. This poses a potential health and safety risk to residents in care	8 9 10 11 12 13 14	The proof of correction is to be received by LPA Knight by 04/04/2023.

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: Lauren Crocker
LICENSING EVALUATOR NAME: Rebecca Knight
LICENSING EVALUATOR SIGNATURE:	DATE: 03/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2023

LIC9099 (FAS) - (06/04)

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