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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191600721
Report Date: 06/24/2022
Date Signed: 06/24/2022 01:07:42 PM


Document Has Been Signed on 06/24/2022 01:07 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 300 N. CONTINENTAL BLVD. #290B
EL SEGUNDO, CA 90245



FACILITY NAME:VISTA DEL MAR CHILD AND FAMILY SERVICESFACILITY NUMBER:
191600721
ADMINISTRATOR:AMY JAFFEFACILITY TYPE:
733
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY:24CENSUS: 18DATE:
06/24/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Jimmy Tyler/Facility Manager TIME COMPLETED:
01:15 PM
NARRATIVE
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On June 24, 2022@ 11:30 AM, Licensing Program Analyst (LPA) Zena Phillips conducted a Case - Management inspection visit. LPA Phillips met with Jimmy Tyler to discuss the video footage of an incident on 02/15/2022, SIR # 797766.

Brief Summary: On February 16,2022 , Community Care Licensing received an incident report for 02/15/2022 reporting restraint of Child #1 by Staff #3 & Staff #4 . LPA Phillips obtained video footage of the incident and observed Staff #3 initiate a a Pro Act restraint by grasping Child #1's left arm and pushed toward wall. LPA Phillips observed Staff # 4 grasp Child #1 right arm to begin wall restraint.

During the investigation LPA Phillips conducted confidential interview, reviewed facility Pro Act certificates and video footage. Requested copies of Pro Act trainers current certification. Based on gathered information there is corroborating evidence that reveals Child #1 was improperly restrained by Staff # 3. The preponderance of evidence standard has been met and the Department has therefore determined the facility is cited for violating Child #1's personal rights.


cont on 809c

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SUPERVISOR'S NAME: Lakescia SmithTELEPHONE: (424) 301-3025
LICENSING EVALUATOR NAME: Zena PhillipsTELEPHONE: 424-301-3076
LICENSING EVALUATOR SIGNATURE:
DATE: 06/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/24/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 300 N. CONTINENTAL BLVD. #290B
EL SEGUNDO, CA 90245
FACILITY NAME: VISTA DEL MAR CHILD AND FAMILY SERVICES
FACILITY NUMBER: 191600721
VISIT DATE: 06/24/2022
NARRATIVE
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the preponderance of evidence standard has been met and the Department has therefore determined substantiated findings for violation of personal rights by Staff #3 on Child #1 as evidence revealed Staff # 3 failed to perform correct Pro Act Restraint on Child #1.

Staff #3s actions on Child #1 poses an immediate health, safety and personal rights risk of harm to children placed in care. The facility is issued a citation in accordance with the Short-Term Residential Therapeutic Program (STRTP) Interim Licensing Standards, Chapter 1; 80072 (a)(3) Personal Rights. See page 809D for deficiencies

Exit interview conducted; Appeal Rights issued, and a copy of this report will be emailed to Administrator.
SUPERVISOR'S NAME: Lakescia SmithTELEPHONE: (424) 301-3025
LICENSING EVALUATOR NAME: Zena PhillipsTELEPHONE: 424-301-3076
LICENSING EVALUATOR SIGNATURE:

DATE: 06/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2022
LIC809 (FAS) - (06/04)
Page: 3 of 3
Document Has Been Signed on 06/24/2022 01:07 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 300 N. CONTINENTAL BLVD. #290B
EL SEGUNDO, CA 90245


FACILITY NAME: VISTA DEL MAR CHILD AND FAMILY SERVICES
FACILITY NUMBER: 191600721

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/24/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/24/2022
Section Cited

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The licensee shall ensure that each child, regardless of whether the child is in foster care, is accorded the personal rights specified in Welfare and Institutions Code Section 16001.9, as applicable....To be free of physical, sexual, emotional, or other abuse, and from corporal or unusual punishment...This requirement was not met as evidenced by:
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Evidence obtained revealed Staff # 3 began improper restraint of Child #1 , by grasping left arm and pusing to wall for restraint, thus posing immediate risk to the safety of children in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Lakescia SmithTELEPHONE: (424) 301-3025
LICENSING EVALUATOR NAME: Zena PhillipsTELEPHONE: 424-301-3076
LICENSING EVALUATOR SIGNATURE:
DATE: 06/24/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/24/2022
LIC809 (FAS) - (06/04)
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