565801257-9-1-2021-29-AS-DPEA-CGQL5P-20220727082725

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 565801257
Report Date: 09/01/2021
Date Signed: 09/01/2021 07:58:09 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
07/27/2021 and conducted by Evaluator Kasandra Lopez

COMPLAINT CONTROL NUMBER: 29-AS-20210727115849

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:	09/01/2021
		UNANNOUNCED	TIME BEGAN:	10:25 AM
MET WITH:	Maria Miranda		TIME COMPLETED:	12:40 PM

ALLEGATION(S):

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Resident sustained an injury while in care.
Staff handled resident in an inappropriate manner.
Staff called resident inappropriate names.
Staff yelled at resident.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) KaSandra Lopez conducted an unannounced subsequent complaint inspection regarding the above allegations 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 10:25 AM and explained the reason for the inspection. Administrator Maria Miranda arrived at the facility shortly after the inspection began.
During today's inspection, the LPA and QAS conducted an interview with Staff #2 (S2) and Staff #3 (S3) between 10:32 AM and 11:15 AM. During a previous inspection on 08/04/2021, the LPA and QAS conducted interviews with Resident #1 (R1), Resident #2 (R2), Resident #3 (R3), Staff #1 (S1), and the Administrator Maria Miranda between 12:07 PM and 1:42 PM.
The allegation of 'Resident sustained an injury while in care' alleges that R1's hand was red and swollen from punching a wall. During interviews with R1, R1 stated they got upset and punched a wall because S3 was pressuring R1 to take a shower.
Report continued on LIC 9099-C.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Kasandra Lopez
LICENSING EVALUATOR SIGNATURE:	DATE: 09/01/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2021

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-20210727115849

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: 09/01/2021

NARRATIVE

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Interviews with S2 revealed R1 was upset when they came home from their day program regarding an incident at program. S2 asked R1 one time only if they wanted to take shower. R1 then walked away and went to their room punching the wall on the way there. An interview with R3 revealed S2 asked R1 to take a shower and then R1 hit the wall. During the interview with S3, S3 stated S2 was the only staff who asked R1 to take a shower and only asked R1 one time to take a shower. Based on the information obtained, there is insufficient evidence to support that licensee is culpable for the resident sustaining an injury in care. Therefore, the allegation of 'Resident sustained an injury while in care' is deemed unsubstantiated at this time.
The allegation of 'Staff handled resident in an inappropriate manner' alleges S3 grabbed R1's hand and twisted it. During the interview with R1, they stated S3 grabbed R1's hand and bent it after R1 hit the wall. During the interview with S3, S3 denied ever bending R1's hand and denied ever placing their hands on R1 at anytime. During the interviews with S1 and S2, both denied ever seeing S3 put their hands on R1. During the interviews with R2 and R3, they stated they both have never observed any staff grab or hurt any residents in the home. Based on the information obtained, there is insufficient evidence to support the allegation occurred. Therefore, the allegation of 'Staff handled resident in an inappropriate manner' is deemed unsubstantiated at this time.
The allegation of 'Staff yelled at resident" alleges S3 yelled at R1 when grabbing and twisting R1's hand. During the interview with S3, they denied ever yelling at R1. Interviews with S1 and S2 revealed they never observed S3 yelling at R1 or any other residents. During the interviews with R2 and R3 they stated they have never heard S3 yell at any residents. Based on the information obtained there is insufficient evidence to support the allegation occurred. Therefore, the allegation of 'Staff yelled at resident' is deemed unsubstantiated at this time.
The allegation of 'Staff called resident inappropriate names' alleges S3 calls R1 names like "stupid" and "crazy". During the interview with R1, they stated S3 tells R1 bad words all the time. During the interview with S3, S3 denied ever cussing or speaking to R1 or any residents inappropriately. Interviews with R2 and R3 revealed they have not heard S3 cuss or say mean things to any residents. Interviews with S1 and S2 revealed no history of S3 cussing or saying inappropriate things to R1 or any other residents. Based on the information obtained, there is insufficient evidence to support the allegation occurred. Therefore, the allegation 'Staff called resident inappropriate names' is deemed unsubstantiated at this time.
Exit interview conducted and report reviewed with the Administrator. A copy of the report and appeal rights will be emailed.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Kasandra Lopez
LICENSING EVALUATOR SIGNATURE:	DATE: 09/01/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2021

LIC9099 (FAS) - (06/04)

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