561703573-11-5-2021-29-AS-KHEN-C8UTYM-20211117140857

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 561703573
Report Date: 11/05/2021
Date Signed: 11/05/2021 02:55:26 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/10/2020 and conducted by Evaluator Joann Rosales

PUBLIC

COMPLAINT CONTROL NUMBER: 29-AS-20200810103613

FACILITY NAME:	ELMS RESIDENTIAL CARE		FACILITY NUMBER:	561703573
ADMINISTRATOR:	HIGGINS, FE LILIA 98		FACILITY TYPE:	740
ADDRESS:	67 EAST BARNETT		TELEPHONE:	(805) 643-2176
CITY:	VENTURA	STATE: CA	ZIP CODE:	93001
CAPACITY:	54	CENSUS: 44	DATE:	11/05/2021
		UNANNOUNCED	TIME BEGAN:	01:35 PM
MET WITH:	Fe Higgins		TIME COMPLETED:	02:54 PM

ALLEGATION(S):

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Resident is intimidating residents
Resident is verbally abusing residents
Resident is violating house rules

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) JoAnn Rosales conducted a subsequent complaint investigation to deliver final investigation findings. LPA met with Administrator Fe Higgins.

Concerns were that resident #1 (R1) is intimidating staff and residents by sneaking up behind them shouting, getting in their face and pointing their finger at them while saying “boom”, “boom”. Concerns were also that R1 is verbally abusing staff and residents by calling them names and cursing at them. Interview conducted on 8/19/2020 at 2:37 pm with the Administrator revealed that R1 does yell and swear but has not been physical with any of the residents. Administrator stated that they will redirect the resident when they are having behavioral episodes. Interview with R1’s Case Manager on 9/15/2020 revealed that due to R1’s diagnosis they are having the behavioral episodes and are easily triggered if someone yells at them. Interviews with staff and residents on 10/18/21 starting at 11:00 am revealed that R1 will verbally intimidate

Continued on 9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Joann Rosales	TELEPHONE: (626) 419-4072
LICENSING EVALUATOR SIGNATURE:	DATE: 11/05/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/05/2021

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 29-AS-20200810103613

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: ELMS RESIDENTIAL CARE	FACILITY NUMBER: 561703573
	VISIT DATE: 11/05/2021

NARRATIVE

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residents, yells and curses at residents and staff due to behavioral episodes and staff will redirect R1. Concerns were that R1 is violating house rules by smoking in their room. Interview conducted on 8/19/2020 with the Administrator revealed that R1 has been told by them and staff not to smoke in their room. Interview with R1’s Case Manager on 9/15/2020 revealed that they have told R1 several times about not smoking in the facility. Interviews with staff and residents on 10/18/21 revealed that R1 smokes in their room and when observed by staff R1 is told not to smoke in their room and to smoke outside in the designated smoking area. Based on the information obtained during the course of the investigation the allegations are deemed unsubstantiated at this time.

A conversation was held with the Administrator today advising them that they need to ensure that the health and safety of all residents is being met. Administrator stated that they will ensure that the health and safety of all the residents is being met. Administrator stated that they will have an outside vendor conduct staff training regarding the proper handling of residents with behavioral episodes.

Exit interview conducted. Today's reports and appeal rights were reviewed and emailed to Administrator.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Joann Rosales	TELEPHONE: (626) 419-4072
LICENSING EVALUATOR SIGNATURE:	DATE: 11/05/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/05/2021

LIC9099 (FAS) - (06/04)

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