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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 557004883
Report Date: 10/06/2021
Date Signed: 10/06/2021 05:05:21 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
10/05/2021 and conducted by Evaluator Sarah Hurt
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20211005131038
FACILITY NAME:WATCHFACILITY NUMBER:
557004883
ADMINISTRATOR:DALY, CHRISTINEFACILITY TYPE:
775
ADDRESS:12801 CABEZUTTELEPHONE:
(209) 533-0510
CITY:SONORASTATE: CAZIP CODE:
95370
CAPACITY:140CENSUS: 43DATE:
10/06/2021
UNANNOUNCEDTIME BEGAN:
04:15 PM
MET WITH:Administrator, Christine DalyTIME COMPLETED:
05:15 PM
ALLEGATION(S):
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Facility violated residents personal rights by not allowing client to attend ADP
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Sarah Hurt arrived at the facility to conduct a complaint investigation on the above allegations. LPA met with Administrator Christine Daley and explained the purpose for todays visit.

It was alleged that the facility violated client’s personal rights by not allowing client to attend the day program. Beginning October 1, 2021, the facility had multiple persons test positive for COVID-19. In response to the positive cases, the facility was advised to have all participants and staff be tested. Per documentation received, Client 1 (C1) agreed to be tested but wanted to go to their own site for testing. Facility representatives were not in agreement with C1 testing elsewhere and advised that testing needed to be conducted through the facility and that C1 could not return to the facility unless the testing occurred as instructed. The facility also advised that they were following CCL PIN 21-33 ASC, which does require response testing, but does not require that the response testing be completed by the facility. PIN 21-33 ASC only required the test be completed.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Sarah Hurt
LICENSING EVALUATOR SIGNATURE:

DATE: 10/06/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2021
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 3
Control Number 27-AS-20211005131038
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: WATCH
FACILITY NUMBER: 557004883
VISIT DATE: 10/06/2021
NARRATIVE
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Based on documents provided the facility did deny Client’s personal rights, therefore the allegation is SUBSTANTIATED. A substantiated finding means that there is a preponderance of evidence to prove that the allegation occurred.

The following deficiency was cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted with Administrator Christine Daly and a copy of this report was provided along with appeal rights and confidential names list.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Sarah Hurt
LICENSING EVALUATOR SIGNATURE:

DATE: 10/06/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 3
Control Number 27-AS-20211005131038
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: WATCH
FACILITY NUMBER: 557004883
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/06/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
10/08/2021
Section Cited
CCR
82072(a)(1
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82072(a)(1) Personal Rights
a) 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.

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Licensee will allow client to attend day program with COVID results from a private provider off site from the facility or allow client to quarantine at the facility.
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This regulation was not met as evidenced by:
The licensee did not ensure that the client was accorded dignity in his/her personal relationships with staff and other persons. Based on documentation received, the facility denied the client from participating in day program services. This poses and immediate risk to the personal rights of clients in care.
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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: Stephenie Doub
LICENSING EVALUATOR NAME: Sarah Hurt
LICENSING EVALUATOR SIGNATURE:

DATE: 10/06/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2021
LIC9099 (FAS) - (06/04)
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