Incident investigation·May 31, 2023

Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to conduct a case management - incident visit. LPA explained the purpose of the visit and met with Administrator (ADM), Shu-Jen Collado and Licensee, Corey Ebadat. During visit, LPA toured the facility with staff to include the garage, resident rooms, bathrooms, living room, kitchen, dining room, and backyard. 3 out of 5 residents observed in the facility. 2 out of 5 residents were stated attending the day program. From 05/23/2023 - 05/26/2023 the Department received several incident reports and SOC341's from the resident (R1)'s day program alleging abuse from the residential facility staff members. It was noted that there was no indication of physical pain or visible marking in the body part areas that were alleged hurt. During visit, LPA interviewed 4 staff members. 4 out of 4 staff members denied the allegation. Staff stated R1 has history of cursing staff and other residents and creating false stories. On 05/23/2023, the ADM received an email from R1's day program regarding the allegations. The ADM responded to R1's day program denying the allegation. ADM informed the day program to review R1's Individual Program Plan (IPP) as the behavior of alleging abuse is part of R1's baseline. ADM stated to have spoken to the facility staff members and R1 regarding the allegation. ADM states all parties including R1 denied the allegation of abuse. A body check was not conducted because ADM states they knew the abuse was not happening as this was part of R1's behavior. ADM advised the facility staff to document the incidents going forward. ADM plans to inform the regional center and consult with R1's behaviorist to create a behavior plan to minimize the allegations. ADM already contracted R1's psychiatrist regarding the behavior. SEE LIC809-C. Based on record review, R1 has moved from another care home due to alleged abuse incident by a peer. Record review states R1 has a behavior in telling false stories as a means of getting attention. LPA obtained R1's IPP, physician's report, and preplacement appraisal information. During visit, LPA entered the garage with staff. LPA observed a staff (S1) sleeping in the garage. ADM stated that S1 lives in the facility. Based on review of the facility sketch, the garage is not approved to be a bedroom. At 11:35am, S1 left the facility. Based on review of the facility's personnel summary, S1 was not associated to the facility roster. LPA reviewed S1's personnel file and observed S1's LIC9182 that was signed by ADM. ADM stated to have faxed the form to the Department on the day S1 was hired 2021. Licensee filled out another LIC9182 and emailed the form to the Department during visit. Based on record review, S1 is fingerprint cleared. A deficiency was cited per California Code of Regulations, Title 22. See LIC809-D. A technical violation was also provided. This report was reviewed with Administrator, Shu-Jen Collado and a copy of the report and appeal rights was provided.