565801844-5-16-2023-29-AS-DPEA-CSBS65-20230530133521

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 565801844
Report Date: 05/16/2023
Date Signed: 05/16/2023 01:25:22 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
04/25/2023 and conducted by Evaluator Kasandra Lopez

COMPLAINT CONTROL NUMBER: 29-AS-20230425142730

FACILITY NAME:	JN GONZALES HOME		FACILITY NUMBER:	565801844
ADMINISTRATOR:	AMANDA G. LEE		FACILITY TYPE:	735
ADDRESS:	4231 NIMITZ DRIVE		TELEPHONE:	(805) 488-0236
CITY:	OXNARD	STATE: CA	ZIP CODE:	93033
CAPACITY:	6	CENSUS: 6	DATE:	05/16/2023
		UNANNOUNCED	TIME BEGAN:	12:01 PM
MET WITH:	Venie Gonzales		TIME COMPLETED:	01:30 PM

ALLEGATION(S):

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Resident is confined inside the facility by staff
Staff are prohibiting resident from speaking to family on the phone
Staff do not answer facility telephone
Staff do not take resident to the store

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) KaSandra Lopez conducted an unannounced subsequent complaint inspection at the facility today regrading the above allegations. Tri-Counties Regional Center Quality Assurance Specialist (QAS) Katy Robison was also present. Administrator Venie Gonzales arrived during the inspection.

During today's inspection, the LPA conducted an interview with Staff #1 (S1) and Client #1 (C1) between 12:09 PM and 12:30 PM. During a previous inspection on 04/27/2023, the LPA conducted a physical plant tour and reviewed facility records. On 05/10/2023, the LPA conducted interviews with two staff members and one client and additional record review was conducted.

Report continued on LIC 9099-C.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Kasandra Lopez
LICENSING EVALUATOR SIGNATURE:	DATE: 05/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2023

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-20230425142730

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: JN GONZALES HOME	FACILITY NUMBER: 565801844
	VISIT DATE: 05/16/2023

NARRATIVE

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Allegation: Resident is confined inside the facility by staff
The allegation alleges Client #1 (C1) is not able to leave their room or use the backyard. Interviews with three staff members revealed C1 is able to leave their room whenever C1's wants or use the backyard. During the interview with C1 they stated they able to leave their bedroom and play basket ball in the backyard. During today's visit and the previous inspection on 04/27/2023, the LPA observed C1 out of their bedroom. Based on the information obtained, there is insufficient evidence to support the allegation occurred. Therefore, the allegation of 'Resident is confined inside the facility by staff' is deemed unsubstantiated at this time.

Allegations: Staff are prohibiting resident from speaking to family on the phone and Staff do not answer facility telephone
The allegations allege when the family member of Client #1 (C1) called the facility to talk with C1, Staff #1 (S1) hung up the phone and did not answer the phone when they tried calling back. During the interview with S1, S1 stated C1 was recently on the telephone with their family member when C1 handed S1 the phone. S1 stated they said hello several times but did not hear a response so they hung up the phone as they thought there was a bad connection. S1 stated after this happened, they began assisting another client using the restroom when the telephone rang. S1 said they were unable to leave this client alone so the phone call was not answered. S1 said the other staff were assisting their 1:1 clients so they also could not answer the phone either. During interview with C1, they stated they are able to make phone calls whenever they want. Based on the information obtained, there is insufficient evidence to support staff intentionally did not answer the telephone when the family member called. Therefore, the allegations of 'Staff are prohibiting resident from speaking to family on the phone' and 'Staff do not answer facility telephone' are deemed unsubstantiated at this time.

Allegation: Staff do not take resident to the store
The allegation alleges C1 is unable to go to the store when C1 has money. The LPA reviewed C1's P&I ledger which reflects C1 has gone on outings in April and May of 2023. During the interviews with staff they stated C1 is taken out on outings during the weekends. During the interview with C1, they stated they recently gone shopping. Based on the information obtained, there is insufficient evidence to support the allegation occurred. Therefore, the allegation of 'Staff do not take resident to the store' is deemed unsubstantiated at this time.
Exit interview and report reviewed with Administrator. A copy of the report and appeal rights provided.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Kasandra Lopez
LICENSING EVALUATOR SIGNATURE:	DATE: 05/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2023

LIC9099 (FAS) - (06/04)

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