525002751-12-30-2021-25-AS-RLBN-CADRQV-20220105121407

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 525002751
Report Date: 12/30/2021
Date Signed: 12/30/2021 01:58:30 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, 520 COHASSET RD., STE. 170
CHICO, CA 95926

This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/28/2021 and conducted by Evaluator Rebecca Knight

COMPLAINT CONTROL NUMBER: 25-AS-20211028104013

FACILITY NAME:	D & S CARE HOMES, LLC		FACILITY NUMBER:	525002751
ADMINISTRATOR:	BORTZ JR, DAVID L.		FACILITY TYPE:	735
ADDRESS:	760 MELTON COURT		TELEPHONE:	(530) 864-2341
CITY:	RED BLUFF	STATE: CA	ZIP CODE:	96080
CAPACITY:	4	CENSUS: 4	DATE:	12/30/2021
		UNANNOUNCED	TIME BEGAN:	01:15 PM
MET WITH:	David Bortz - licensee/administrator		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Client sustained unexplained injuries while in care - UNSUBSTANTIATED

INVESTIGATION FINDINGS:

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12/30/2021 1:15 PM Licensing Program Analyst (LPA) Rebecca Knight arrived at the facility unannounced to deliver the results of a complaint investigation. LPA met with licensee / administrator David Bortz and explained the purpose of the visit was to deliver complaint investigation results for the above allegation. Prior to initiating the complaint investigation LPA completed required COVID-19 testing protocols, and 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 LPA interviewed 1 administrator, 4 staff, and 3 clients. LPA reviewed the following documents: Staff list with telephone numbers, photographs of client, client’s physician’s report (LIC-602), client’s Individual Program Plan (IPP).
Continued on LIC9099-C.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Rayna L Bryson
LICENSING EVALUATOR NAME: Rebecca Knight
LICENSING EVALUATOR SIGNATURE:	DATE: 12/30/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/30/2021

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 25-AS-20211028104013

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: D & S CARE HOMES, LLC	FACILITY NUMBER: 525002751
	VISIT DATE: 12/30/2021

NARRATIVE

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Client sustained unexplained injuries while in care – UNSUBSTANTIATED

It was alleged that the client sustained unexplained injuries while in care. It was reported that the client had a large silver dollar size abrasion on their forehead and a red abrasion on their nose.

The licensee stated that the client did have an abrasion on their forehead with no discoloration. Licensee stated they thought that the client could have hit their head on the headboard of the client’s bed. Licensee stated that the client would sometimes place their head in the cubby holes of the headboard.

On 11/03/2021 during LPA’s tour of the facility, LPA inspected the client’s bedroom and observed a wooden headboard with “cubby holes” in it. The licensee has since removed the headboard with cubby holes from the client’s bedroom in order to reduce the risk of injury.

During staff interviews it was learned that staff either saw a mark on the client’s forehead or heard that the client had a mark on their forehead. 3 staff stated that the client may have hit their head on the headboard of their bed. 3 staff stated that the headboard has been removed from the client’s room.

On 12/30/2021 LPA Knight toured the facility and confirmed that the headboard had been removed from the client's bedroom.

During client interviews 2 of 3 clients stated they were not aware of any client in the home with any injuries. 1 client is non-verbal and was not able to be interviewed.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred, and the findings are unsubstantiated.

An exit interview was conducted. A copy of the report was emailed to facility licensee /administrator David Bortz. No deficiencies were cited on today’s date.

SUPERVISORS NAME: Rayna L Bryson
LICENSING EVALUATOR NAME: Rebecca Knight
LICENSING EVALUATOR SIGNATURE:	DATE: 12/30/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/30/2021

LIC9099 (FAS) - (06/04)

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