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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331800086
Report Date: 04/29/2024
Date Signed: 04/29/2024 12:55:09 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/04/2020 and conducted by Evaluator Sara Martinez
COMPLAINT CONTROL NUMBER: 18-AS-20200904122837
FACILITY NAME:CALIFORNIA HOME FOR THE ADULT DEAF (CHAD)FACILITY NUMBER:
331800086
ADMINISTRATOR:CASTRO, MICHAELFACILITY TYPE:
740
ADDRESS:3615 CROWELL AVETELEPHONE:
(951) 324-1601
CITY:RIVERSIDESTATE: CAZIP CODE:
92504
CAPACITY:6CENSUS: 5DATE:
04/29/2024
UNANNOUNCEDTIME BEGAN:
11:10 AM
MET WITH:Danny Barret - LicenseeTIME COMPLETED:
01:10 PM
ALLEGATION(S):
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Facility staff are not properly trained
Facility staff are restraining resident
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Sara Martinez conducted an unannounced visit to conclude the investigation and deliver findings for the allegations listed above. LPA was granted entry and met with Licensee Danny Barret and explained the purpose of the visit.

Regarding the allegation “Facility staff are not properly trained” it was alleged that Staff One (S1) was working at the facility without completing their training. LPA conducted interviews and record review regarding the allegation. Interviews with Administrator Barret on 09/10/2020 revealed that two of the staff members had not completed the 20 and 40 hours of training for the year per Health and Safety Code 1569.625 and 1569.69. Administrator Barret’s interview revealed S1 had not yet completed the required training for the year. Therefore, based on interviews and record review the allegation facility staff are not properly trained has been deemed SUBSTANTIATED at this time.

Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Sara Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 04/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/04/2020 and conducted by Evaluator Sara Martinez
COMPLAINT CONTROL NUMBER: 18-AS-20200904122837

FACILITY NAME:CALIFORNIA HOME FOR THE ADULT DEAF (CHAD)FACILITY NUMBER:
331800086
ADMINISTRATOR:CASTRO, MICHAELFACILITY TYPE:
740
ADDRESS:3615 CROWELL AVETELEPHONE:
(951) 324-1601
CITY:RIVERSIDESTATE: CAZIP CODE:
92504
CAPACITY:6CENSUS: 5DATE:
04/29/2024
UNANNOUNCEDTIME BEGAN:
11:10 AM
MET WITH:Danny Barret - Licensee TIME COMPLETED:
01:10 PM
ALLEGATION(S):
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9
Resident was left on the floor for an extended period of time
Facility staff are mismanaging resident's medication
INVESTIGATION FINDINGS:
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pLicensing Program Analyst (LPA) Sara Martinez conducted an unannounced visit to conclude the investigation and deliver findings for the allegations listed above. LPA was granted entry and met with Licensee Danny Barret and explained the purpose of the visit.

Regarding the allegation “Resident was left on the floor for an extended period of time” it was alleged Resident One (R1) was laying on a mattress on the floor and was found in the morning with no explanation from staff. LPA conducted interviews and record review regarding Resident One (R1). Interview with Administrator Danny Barrett revealed due to R1’s prescribed medication from their physician, there was an incident where R1 was zoning out and leaning forward while in their wheelchair. A staff member assisted R1 to lay on the floor so no injuries would occur. Staff informed Administrator Barrett of R1’s condition and implemented a plan off care for R1 to sleep on a mattress on the floor overnight to prevent injury. Administrator Barrett stated this was the only incident where R1 slept overnight on a mattress on the floor for a duration of approximately 10 hours.

Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Sara Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 04/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 18-AS-20200904122837
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: CALIFORNIA HOME FOR THE ADULT DEAF (CHAD)
FACILITY NUMBER: 331800086
VISIT DATE: 04/29/2024
NARRATIVE
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LPA toured the facility on 12/11/2023 and did not see any mattress pads on the floor in the residents’ room. LPA conducted interviews with staff and residents with an interpreter present that did not provide any corroborating evidence that support resident was left on the floor for an extended period of time with no explanation from staff. Therefore, based on interviews, record review, and observation, the allegation “Resident was left on the floor for an extended period of time” is deemed UNSUBSTANTIATED at this time.


Regarding the allegation “Facility staff are mismanaging resident's medication” LPA conducted record review of the Medication Administration Record (MAR) for three (3) residents and found no discrepancies with the MAR and mediation count. Record review of the MAR and LPA’s observation of the medication reveal staff were administrating resident’s medication per the physicians’ orders. Record review and interviews with staff and residents reveal medication was being managed by staff and the residents were receiving their prescribed medication daily. Therefore based on interviews, record review, and observation, the allegation “Facility staff are mismanaging resident's medication” is deemed UNSUBSTANTIATED at this time.

A finding that the complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

An exit interview was conducted and a copy of this report was reviewed with and provided to Licensee Danny Barret.
SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Sara Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 04/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 18-AS-20200904122837
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: CALIFORNIA HOME FOR THE ADULT DEAF (CHAD)
FACILITY NUMBER: 331800086
VISIT DATE: 04/29/2024
NARRATIVE
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Regarding the allegation “Facility staff are restraining residents” it was alleged Resident One (R1) had been restrained on their bed with two pillows placed by R1’s side to prevent R1 from moving. Interviews with Administrator Barrett revealed the facility puts two pillows on R1’s right side to keep R1 from rolling out of bed onto the floor. Record review revealed R1 has a history of falls per R1’s physicians report. However, there was no written care plan from a medical professional in place for R1 to have postural supports. Therefore, based on interviews and record review the allegation facility staff are restraining residents has been deemed SUBSTANTIATED at this time.

A finding that the complaint is SUBSTANTIATED means that the allegation(s) is valid because the preponderance of the evidence standard has been met.
An exit interview was conducted and a copy of this report, 9099C, 9099D, LIC 811, and appeal rights were provided to Licensee Danny Barret.
SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Sara Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 04/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 18-AS-20200904122837
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: CALIFORNIA HOME FOR THE ADULT DEAF (CHAD)
FACILITY NUMBER: 331800086
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/29/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/10/2024
Section Cited
CCR
87411(c)
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87411 Personnel Requirements - General (c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69
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Licensee will ensure all staff are have completed the initial and annual training as specified in Health and Safety Code 1569.625 and 1569.69. Licensee will submit proof of staff training to LPA by the agreed Plan of Correction date.
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This requirement is not met as evidence by: based on interview and record review the licensee did not comply by having S1 assist residents with personal activities of daily living without fulfilling the annual required hours of training which poses a potential health, safety or personal rights risk to persons in care.
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Type B
05/10/2024
Section Cited
CCR
87608(a)(3)
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87608 Postural Supports (a) Based on the individual's... appraisal, the facility shall provide assistance and care… Postural supports may be used under the following conditions. (3) A written order from a physician indicating the need for the postural support.This requirement is not met as evidence by:
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Licensee agreed to send LPA a written and signed statement stating Licensee and staff read and understood regulation 87608 regarding Postural Supports. Licensee will submit statement to LPA by Plan of Correction date.
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Based on interviews and record review, the Licensee did not ensure R1 had a written order from Physician for pillows to be placed on the side of R1 while laying in bed to ensure R1 did not fall off. R1 is no longer a resident. This poses a poses a potential health, safety or personal rights risk to persons 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.
SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Sara Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 04/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5