565801257-7-23-2021-29-AS-DPEA-CDHNFC-20220415102518

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 565801257
Report Date: 07/23/2021
Date Signed: 07/23/2021 04:38:57 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, 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
07/22/2021 and conducted by Evaluator Kasandra Lopez

PUBLIC

COMPLAINT CONTROL NUMBER: 29-AS-20210722093350

FACILITY NAME:	EJ2 FAMILY HOME		FACILITY NUMBER:	565801257
ADMINISTRATOR:	MARIA MIRANDA		FACILITY TYPE:	735
ADDRESS:	1210 NELSON PLACE		TELEPHONE:	(805) 271-9449
CITY:	OXNARD	STATE: CA	ZIP CODE:	93033
CAPACITY:	6	CENSUS: 6	DATE:	07/23/2021
		UNANNOUNCED	TIME BEGAN:	09:24 AM
MET WITH:	Jomar Ong		TIME COMPLETED:	12:20 PM

ALLEGATION(S):

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Staff locked resident out of facility.
Staff did not administer medication(s) to resident according to physician's instructions.
Resident was not provided food.
Resident was not provided water.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) KaSandra Lopez conducted an unannounced initial complaint inspection at the facility today. Tri-Counties Regional Center Quality Assurance Specialist (QAS) Liz Aced-Arnett was also present during the inspection. The LPA and QAS met with facility staff at 9:24 AM and explained the reason for the inspection. Administrator Jomar Ong arrived at the facility at 9:33 AM.

During today's inspection the LPA and QAS conducted interviews and reviewed medications and records. At 9:34 AM, an interview was conducted with Resident #1 (R1). At 10:06 AM medications and medication records for R1 were reviewed. Between 10:18 AM and 10:54 AM, interviews were conducted with Staff #1, Staff #2, Staff #3 and Jomar Ong.

Report continued on LIC 9099-C.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Kasandra Lopez
LICENSING EVALUATOR SIGNATURE:	DATE: 07/23/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/23/2021

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-20210722093350

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: EJ2 FAMILY HOME	FACILITY NUMBER: 565801257
	VISIT DATE: 07/23/2021

NARRATIVE

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Interviews revealed on July 16th, 2021, R1 became upset after a movie R1 wanted to watch was unavailable and R1 went outside in the front yard area of the facility. During the interview with R1, R1 stated they chose to stay outside because they were upset. R1 stated staff watched R1 while they were outside. R1 stated they were offered food and water by staff but refused it. R1 also stated they received their medications.

Interviews with staff revealed staff watched R1 while R1 was outside. Staff stated they offered R1 food and water but R1 refused. Staff #1 (S1) stated R1 refused their medication initially but S1 was able to get R1 to take their medication after several prompts. Staff interviewed denied not allowing R1 back into the facility.

Medication and record review revealed R1 took their scheduled medications.

Based on the information obtained during the investigation, there insufficient evidence to support the allegations of "Staff locked resident out of facility", "Staff did not administer medication(s) to resident according to physician's instructions", "Resident was not provided food", and "Resident was not provided water". Therefore, the allegations are deemed unsubstantiated at this time.

Exit interview and report reviewed with Administrator Jomar Ong. A copy of the report and appeal rights will be emailed.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Kasandra Lopez
LICENSING EVALUATOR SIGNATURE:	DATE: 07/23/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/23/2021

LIC9099 (FAS) - (06/04)

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