Complaint Investigation Report

019200543-6-24-2025-15-AS-KHOS-DJMKRN-20250716080812

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

This is an official report of an unannounced visit/investigation of a complaint received in our office on

06/23/2025 and conducted by Evaluator James Sampair

COMPLAINT CONTROL NUMBER: 15-AS-20250623155533

Staff did not prevent client in care from getting hit by a non-client youth

On 6/24/2025, at 3:30 PM, Licensing Program Analyst (LPA) James Sampair arrived unannounced at the facility to investigate the allegation above. Upon entry into the facility, the LPA identified himself and stated the purpose of the visit to Caregiver Thelma Black.

The complaint alleges that staff did not prevent client in care from getting hit by a non-client youth.

The LPA interviewed Witness W1, reviewed the Special Incident Report and Daily Charting Notes on 6/23/2025, and interviewed Staff S1 and S2. The data collected shows that the staff put the client at risk by bringing a non-client youth into the facility and providing inadequate supervision, confirming the allegation.

The preponderance of the evidence standard has been met, and the allegation is SUBSTANTIATED.

Deficiency is cited under the California Code of Regulations listed on LIC 9099-D. Failure to submit proof of correction (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties.

Exit interview conducted, Appeal Rights, and a copy of this report provided.