565801347-6-21-2023-29-AS-DPEA-CZXVV2-20240129154535

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 565801347
Report Date: 06/21/2023
Date Signed: 06/21/2023 12:51:35 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
03/14/2023 and conducted by Evaluator Kasandra Lopez

COMPLAINT CONTROL NUMBER: 29-AS-20230314153949

FACILITY NAME:	GRACE ADULT RESIDENTIAL FACILITY		FACILITY NUMBER:	565801347
ADMINISTRATOR:	LOUISA CERVANTES		FACILITY TYPE:	735
ADDRESS:	3005 LASSEN STREET		TELEPHONE:	(805) 486-2832
CITY:	OXNARD	STATE: CA	ZIP CODE:	93033
CAPACITY:	5	CENSUS:	DATE:	06/21/2023
		UNANNOUNCED	TIME BEGAN:	12:15 PM
MET WITH:			TIME COMPLETED:	01:00 PM

ALLEGATION(S):

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Staff #1 (S1) physically abused Client #1 (C1) by pushing C1 resulting in a fractured hip.
Facility staff hit Client #1 (C1).

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) KaSandra Lopez conducted a subsequent complaint visit to deliver findings for the above allegations. LPA met with Licensee Julia Espena and explained the reason for the visit. Tri-Counties Regional Center Qualifiy Assurance Specialist (QAS) Liz Aced-Arnet was also present. Administrator Louisa Cervantes arrived during the inspection.

On 03/14/2023, the Department received a complaint regarding allegations of physical abuse. It was alleged that Staff #1 (S1) physically abused Client #1 (C1) by pushing C1 resulting in a fractured hip; and Facility staff hit Client #1 (C1). The complaint was referred to the Community Care Licensing Investigations Branch (IB) and assigned to Investigator Christine Ferris.

On 03/15/2023, from 9:45 a.m. to 11:20 a.m., LPA KaSandra Lopez conducted an unannounced initial 10-day complaint inspection at the facility. During the inspection the LPA conducted a physical plant tour, then began record review at 9:55am. Report continued on LIC 9099-C.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Kasandra Lopez
LICENSING EVALUATOR SIGNATURE:	DATE: 06/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2023

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-20230314153949

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: GRACE ADULT RESIDENTIAL FACILITY	FACILITY NUMBER: 565801347
	VISIT DATE: 06/21/2023

NARRATIVE

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An interview was conducted with Staff #1 (S1) at 10:01am. The LPA also conducted interviews with Licensee Julia Espena and Administrator Louisa Mae Cervantes during the inspection. Copies of pertinent records were obtained.

Investigator Ferris conducted interviews on 04/03/2023 with the Administrator, Staff #1 (S1), Licensees, clients, Client #1 (C1), and the reporting party; and on 05/08/2023, with the Tri-Counties Regional Center (TCRC) Service Coordinator (SC). In addition, Investigator Ferris reviewed St. John’s Regional Medical Center medical records and facility file documents related to C1 and S1.

A review of C1’s physician reports, dated 02/14/2019 and 07/27/2021, indicated C1 is diagnosed with cognitive developmental delay, chronic ataxia, able to independently transfer to and from bed, ambulatory, non-verbal, bathes, feeds, and dresses self, able to care for own toileting needs, unable to ambulate without assistance. The Individual Program Plan (IPP) dated 12/30/2022, documented C1 was attending a community-based program, is ambulatory, due to limited safety awareness and unsteady gait, must be supervised, enjoys dancing, helping roommate and making own bed. The facility Identification and Photo sheet updated 02/15/2023, lists C1 as non-verbal, diagnosis of mild mental retardation, moderate cerebral palsy, and walks with an unsteady gait.

According to the Special Incident Report (SIR) submitted by the facility, on 03/05/2023 C1 was using the restroom in between lunch, when S1 went to check on C1. As S1 entered the restroom to assist C1, C1 stood up abruptly and lost balance, falling on left hip. S1 was able to hold C1 and not hit their head on the floor. 9-1-1 was called and C1 was taken to St. John’s Regional Medical Center.

A review of the St. John’s Medical Center medical records indicated the following: C1 was admitted 03/05/2023, due to a fall at the facility. C1 slipped and fell directly on left hip. History of the present illness indicated C1 has Cerebral Palsy and mild mental retardation. X-rays revealed a left hip fracture with no reported history of prior broken bones. Surgery was performed and C1 was discharged on 03/10/2023, to a Skilled Nursing Facility (SNF) for rehabilitation and physical therapy. Investigator Ferris noted the medical records did not document any evidence or suspicion of physical abuse.

Report continued on LIC 9099-C.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Kasandra Lopez
LICENSING EVALUATOR SIGNATURE:	DATE: 06/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2023

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20230314153949

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: GRACE ADULT RESIDENTIAL FACILITY	FACILITY NUMBER: 565801347
	VISIT DATE: 06/21/2023

NARRATIVE

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Information obtained during the interview process revealed that C1 stated they were not pushed, hit, or harmed by anyone at the facility. S1 denied pushing, hitting, or harming C1 in any manner. Staff and clients denied any knowledge of physical abuse. Per the TCRC SC, there were never any concerns of abuse of C1 or the other clients that they managed at the facility. C1 resided at the facility for ten years and never sustained any injuries prior to this incident.

The Department found no evidence supporting the allegations, therefore, the allegations of Staff #1 (S1) physically abused Client #1 (C1) by pushing C1 resulting in a fractured hip” and “Facility staff hit Client #1 (C1)” are deemed Unsubstantiated at this time.

Exit interview, copy of report was provided.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Kasandra Lopez
LICENSING EVALUATOR SIGNATURE:	DATE: 06/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2023

LIC9099 (FAS) - (06/04)

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