405802280-5-21-2024-29-AS-KBUY-D5PPUD-20240528113723

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 405802280
Report Date: 05/21/2024
Date Signed: 05/21/2024 04:29:12 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
05/13/2024 and conducted by Evaluator Rachael De Leon

COMPLAINT CONTROL NUMBER: 29-AS-20240513121541

FACILITY NAME:	C.A.L.L. - VALDEZ HOUSE		FACILITY NUMBER:	405802280
ADMINISTRATOR:	KYLAN REYNOSO		FACILITY TYPE:	740
ADDRESS:	4305 VALDEZ AVE		TELEPHONE:	(805) 460-6663
CITY:	ATASCADERO	STATE: CA	ZIP CODE:	93422
CAPACITY:	4	CENSUS: 4	DATE:	05/21/2024
		UNANNOUNCED	TIME BEGAN:	10:05 AM
MET WITH:	Kylan Reynoso, Administrator		TIME COMPLETED:	04:35 PM

ALLEGATION(S):

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Facility staff do not meet resident’s incontinence needs
Facility staff do not ensure resident's hygiene needs are being met

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) De Leon conducted a 10 day complaint visit to the facility above. LPA was greeted by staff that contacted Administrator. Administrator arrived to the facility to meet with LPA, LPA explained the purpose of the visit.

LPA requested the following records: All four residents LIC 602A Physicians report, Resident 1 (R1) Appraisal Needs and Services Plan, R1's IPP/ISP/Behavioral plans from TCRC, any of R1's hospital discharge paperwork for April/May 2024, Resident Roster, Staff Roster, Staff Schedule for April/May 2024.
LPA conducted interviews with Staff. Residents at the facility were unable to be interviewed.
LPA reviewed R1's records at the facility. R1's records were up to date. R1's LIC 602A Physicians report is dated 08/01/2023, Supports Intensity Scale Adult Version profile information dated 11/20/2023 and 04/04/2024, Praise Behavioral Support Plan dated 04/04/2024, Individual Program Plan Agreement dated 05/01/2024, Individual Service Plan dated 05/01/2024, continued 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Rachael De Leon
LICENSING EVALUATOR SIGNATURE:	DATE: 05/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2024

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-20240513121541

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: C.A.L.L. - VALDEZ HOUSE	FACILITY NUMBER: 405802280
	VISIT DATE: 05/21/2024

NARRATIVE

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Behavior Plan at a Glance dated 04/04/2024, Twin Cities Community Hospital Discharge dated 05/12/2024 and all forms were current. The facility is keeping up with all plans to provide R1 the best possible care with the refusal behaviors at this time.

On the allegation: Facility staff do not meet resident’s incontinence needs. Based on interviews the staff at the facility do change R1 several times a day, use wipes to clean R1 and sponge bath R1 daily. The staff have not been able to get R1 to take a shower due to R1's refusals. The staff have tried different times of the day and different staff asking R1. R1 is only allowing a few staff to help R1 and it has been by wipes or sponge bathing. R1 used to use the restroom but R1 has been incontinent wearing briefs now since November of 2023. R1 had a recent 911 ER visit due to staff coming on shift worried about R1 and that R1's refusals may have lead to sores and or sepsis. R1's discharge from the ER did not have any notations in regards to neglect, sores or sepsis. The discharge diagnosis was Abdominal Pain with Diarrhea and a follow up appointment with Primary Care Physician (PCP) was requested. R1 has an appointment on June 6, 2024 at 2:15pm which was the soonest staff was able to get R1 in to see PCP. Tri-Counties Regional Center (TCRC) placed R1 at this facility in 06/2023 and the facility has had meetings with TCRC about R1. The most recent team meeting regarding R1 was held 05/01/2024 with facility Administrator, R1, TCRC and Behaviorist. Everyone is aware of R1 and the refusals to shower. The facility is currently working with TCRC on placement for R1. Based on the evidence this allegation is Unsubstantiated at this time.

On the allegation: Facility staff do not ensure resident's hygiene needs are being met. Based on staff interviews R1 has been refusing showers. R1 is being changed several times thorough out the day. R1 is getting wiped down daily and R1 is getting sponged bathed Monday-Friday on a regular basis. R1 was showered recently on Noc shift early morning on the 12th by staff 5 (S5), R1 would not allow for R1's hair or face to be washed but allowed S5 to use a washcloth to clean R1's body, R1 was also given a wash cloth to help clean R1's self. Staff at the facility called 911 and R1 went to the ER later that afternoon on the 12th, the staff that came on duty felt R1 had not been cleaned since the prior day and was worried that R1 would have skin breakdown, sores and or sepsis. The discharge paperwork was reviewed by LPA and had no mention of neglect, sores or sepsis. The ER diagnosis was abdominal pain. The facility staff are working with TCRC and Behaviorist to help R1 with R1's changing behaviors.

Continued 9099-C

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Rachael De Leon
LICENSING EVALUATOR SIGNATURE:	DATE: 05/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2024

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20240513121541

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: C.A.L.L. - VALDEZ HOUSE	FACILITY NUMBER: 405802280
	VISIT DATE: 05/21/2024

NARRATIVE

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The facility has spoken with TCRc about possible placement of R1 to another facility. LPA spoke with TCRC Quality Assurance staff that stated they were made aware of the shower refusals and are now aware of the possible placement to another facility for R1. R1 is incontinent and R1 does refuse showers. The staff try daily to shower R1 and sometimes are not able to due to R1's refusal and agitation. Based on the evidence this allegation is deemed Unsubstantiated at this time

Exit interview conducted and copy of report printed for Administrator

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Rachael De Leon
LICENSING EVALUATOR SIGNATURE:	DATE: 05/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2024

LIC9099 (FAS) - (06/04)

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