Complaint Investigation Report

331880894-12-9-2021-18-AS-KCLS-C9SQZS-20211217113712

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

CCLD Regional Office , 1650 SPRUCE ST STE 200 MS29-27

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

03/08/2021 and conducted by Evaluator Javier Prieto

COMPLAINT CONTROL NUMBER: 18-AS-20210308084951

Facility is not providing adequate supervision per agreement.

Licensing Program Analyst (LPA) Javier Prieto conducted a complaint investigation alleging “Facility is not providing adequate supervision per agreement”. Due to COVID 19 and social distancing the complaint was conducted, via telephone. LPA identified himself and discussed the purpose of the call and the elements of the allegation with the Administrator Keith Walker. Walker states resident #1 (R1) has a 1:1 staff supervision. On 03/09/2021, R1 was in the bathroom, locked the door and caused self-injury while locked in facility’s bathroom. R1 was sent to the hospital and placed on a 5150 hold. This was reported to R1’s Placement agency, and CCL via special incident report (SIR). Review of R1’s facility file documents revealed a history of behavioral, and self-injury. R1 was moved from facility at time of investigation and not available for interview.

Based on the information obtained there is not enough evidence that facility is not providing adequate supervision per agreement. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.