Aromas oepaRreNT OF soci ences FACILITY EVALUATION REPORT Se Reece 271 ERTURA MAD, STE 280 FACILITY NAME: AACRES - BIRCHER ST FACILITY NUMBER: 197608985 ADMINISTRATOR: BRITTANY BENFORD FACILITY TYPE 735, ADDRESS: 16544 BIRCHER ST ‘TELEPHONE: (310) 327-7842 cry: GRANADA HILLS STATE:CA 217 CODE: 91344 CAPACITY: 4 CENSUS:2 DATE: s2re1/2017 TYPE OF VISIT: Orfico UNANNOUNCED TIME BEGAN: 04:00 PM MET WITH: ____Anthony McConnell - Regional Director ‘TIME COMPLETED: 06:45 PM. NARRATIVE TPA Gary Tan met with Anthony MaConnell, Regional Director and Heather Diaz, Gually Inprovement Director at the Woodland Hills Regional Office to deliver the report. (On May 16, 2017 the licensee submitted an incident report to the Deparment that on May 14, 2017 Client #2 was fatally stabbed by Client #1 (see confidential namas ist). The incident ropor investigation revealed that ‘on May 14, 2017, Cilent #1 had access to a 4” knife by unlocking the cabinet which stored sharps. Staff interviews confirmed that the keys for the locked cabinet were kept in an unlocked drawor. A review ol the readmission appraisal and other admission documentation trom the placement agency showed that the Client had a history of physical aggressive acts towards others. The administrator admitted to having ‘observed this behavior. Investigation also revealed thatthe census on the day ofthe incident was four (8) clients and only one (1) direct support professional on duty. The licensee's approved Regional Center Program Design states that ‘A ‘basic staffing lovel of no less than one direct support professional fortwo persone (a ratio of 1:2) will be provide during typical waking hours and at night there wil be two awake direct support professionals on duty {and one overnight staff ready to work if called (on call)" Staff schedule and interviews with the administrator and staff contirmed that there was only (1) direct support professional scheduled forthe nocturnal shift on the night ofthe incident, A review of the individual program plans (IPP) for Clients #1 and #2 also revealed that Cliont #1 required one ‘on ono (1:4) stating, and Client # 2 required fifteen (15) minutes visual check while sleeping. Interviews with Statf #1 (S1), Administrator and Regional Director were not aware that Cliant #2 required fifteen (15) minutes Visual check while sleaping in her bedroom, (On June 21, 2017 a non-compliance conference was held with the licensee, representatives of the placement agency, Northern Los Angeles County Regional Center, and tho Departments stat. The licensee was, informed that the Department would be issuing deficiencies for failure to meet licensing requirements and @ civil penalty might be assessed based on Health and Safely Code § 1548(0) (1) BRBRSSSGHATARASeevouson4| lex Eatrade LICENSING EVALUATOR NAME: Joso Gary Tan ‘TELEPHONE: (228) 213-1149, LICENSING EVALUATOR SIGNATURE: — tw e~ DATE: 12/21/2017, Vacknowiedge receipt of this form and understand my licensing appeal rights as explained and recolved. FACILITY REPRESENTATIVE SIGNATURE: : Axly ia 1212017 This report must be available at Child Care and Group Home facilities for public review for 3 years, con ras) 0600) PagesSTATE OF CALIFORMWA-HEALTH AND HUMAN SERVICES AGENCY ALORA oepaRTuET oF coc seRvCes cero eae Lees ona FACILITY EVALUATION REPORT (Cont) $egRygora ves a yun, see FACILITY NAME: AAGRES - BIRCHER ST FACILITY NUMBER: 197608965 \VistT DATE: 1221/2017 NARRATIVE 7 2 3 | Based on the above noted investigation findings, the iconsee'ssfalure to provide adequate care and 4 | Supervision contributed tothe death of Glent #2: The following ctations ar issued for voltion of California 55 | Code of Regulations (CCR) Tile 22, §85078(a)(1) Responsibity for Providing Care and Supersion: The 6 | consee shal provide those services identified inthe clonts needs and services plan as necessary fo meet 7 | the cients needs: 80065 (a) Personne! Requirements: Facity personnel shall be competent fo provide the 8 | sevces necassary to mast individual cient needs and shall, at all mes, be employed in numbers necessary 3 | to moot such needs; §80072(a)(2) Personal Rights: Each liont has the right lo be accorded sae, healthful ‘and comfortable accommodations, furnishings and equipment to meet his/her needs ; and §80087(g) Buildings and Grounds: Disinfectants, cleaning solutions, poisons, and other items that could pose a dangor to clients shall be inaccessible. ‘Today, after careful evaluation, the Department determined that the facility's violation resulted tothe death of ‘2 Clent and therefore per Health & Safety Code §1548(e)(1), the Departmont is issuing a $15,000.00 Cul Penalty ‘Appeal rights provided. Exit interview conducted Ur SBT 7 TELEPHONE: (323) 219-1149 Alex Eada LICENSING EVALUATOR NAME: Joso Gary Tan LICENSING EVALUATOR SIGNATURE: NTF OOO DATE: 12/21/2017 {Tacknowiedge receipt of this form and understand my appeal rights as explained and recelved. FACILITY REPRESENTATIVE SIGNATURI DATE: 12/21/2017, cso ras) 0004) Peaster‘STATE OF CAHIFAIRIMH/AND HUMAN SERVICES A‘ FACILITY EVALUATION REPORT (Cont) FACILITY NAME: AACRES - BIRCHER ST DEFICIENCY INFORMATION FOR THIS PAGE: {SLO Rahn fen 21731 VENTURA BLD, STE. 250 ‘StooouAne nas, ch rae FACILITY NUMBER: 197608985 VISIT DATE: 12/21/2017 Deficiency Type POC Due Date DEFICIENCIES PLAN OF CORRECTIONS(POCs) Section Number 1] Personal Rights. Each cient has the right tobe| 1] There had been no admission of any cent to pay 2| accorded sate, heathland comvfonabie |2| ho faclly since 08/14/17. For ture ype, | accommocation, tumishings and equipment to] 3 | admissions, the pre-admission process has saevi2017 | meet hiamer noods, 4 [been enhanced to Inckide review by acini Sectionctea | 5 5 [team member wit recommendston for 6 | Based on the preacmiasion appraisal and ater 6 | suppor and supeciion. nc7217@ | 7] Semssion decumoninioneeehedtom |? | ows aspen 8 | tho placement agency and observation of | 8| taf are trained on the cent’ pln prior to 8 | Gient #1 (C1) behavior after admission tothe || admission. Reviow of elon plans, neods, and 0] facity, iconsee was aware that Ct had [10] supports occur dung rosin sat! meatings, 13] exerted physical aggressive acts towards {11 12 others, yt ‘aed o provide adequate lr 19| supervision io eneure the saaty ofa cents [13 14) undoes cre, I 1 | Bullings and Grounds. Disinfectants, cleaning 1 | After the incident, immeclate changes were ek 2| solutions, poisons, ané othr tems tal could | 2 | implemented by th facity by entancing the 2 pose a danger to cients shal be inaccessible, | | policy for keys tobe kept on tho sal’ porson 1221/2017 | || Lleensee maintained al shar toms, such az | 4 |At ait change tne key re tansioved tone ‘Section Cited | 5 knives and scssore i a pass ool box which | 5 | encoming stat cor 8 | was paced insigea locked cabinet. On the |8 | Licensee agreed to submit copy of the new 008716) 7 | date of the incident, 7 | poly for keys. 8 | tho kay that was used to unlock the cabinet | | was kept in an unlocked a 8 10] area. Asa result, C1 was. lo 11] key and gained access to the toolbox that was [1 12} kept inside tho locked cabinet. A kite was {12 13] usec 2s a weapon to stab C2 resulting mn her [13 14] oat | Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may resull In a civil penalty assessment. ‘SUPERVISOR'S NAME: Alex Estrada Ue ATOR ey eg Ko acknowledge receipt of this form and understand my appeal rights as explained and received. nary seggen ume ARVALU Lucas ras (0200 ‘TELEPHONE: (918) 596-4364 ‘TELEPHONE: (328) 213-1149, DATE: 12/21/2017 DATE: 12/21/2017STATE OF CALFORMA- HEALTH AND HUUAN SERVICES AGENCY Carona oepanruent oF soca semvcss ‘Soanunt eae cena Bon FACILITY EVALUATION REPORT (Cont) Oooo ae, crise TU ABMR STE FACILITY NAME: AAGRES - BIRCHER ST FACILITY NUMBER: 197608985 DEFICIENCY INFORMATION FOR THIS PAGE: VISIT DATE: 1272172017 Deticoney Type POC Due Date DEFICIENCIES PLAN OF CORRECTIONS(POCS) Section Number | [eons or Proving Gare ana + ptr cider, mediate changes wore 2) Stparision: Te Kensoe shal prove these || implemented byte ality o ete home Tye A 5 sence emg te cients needs and |2| sat meeingsSonccted on one os ovosore |) series plan as nocassry to most he cients |3 | (miamom suman oven cont PP, Section cited [5 | neds {needs and suppor” Spo vanngson topes ‘coe § | Glen's individual program plan (PP) state S| such ae moieaone, cysicl entronmer, asoreiayt) || thatcton waa o be visuly checked every 19 | int ile oh was asanp ‘Stat 4 (81) on duty ath ight ne continent reporting, cnt ight andsuppos had worked night shits tom 10 PM to 8 AM a! | are conducted as needed dung unannaanco {i fait forhe past 5 ments porto the | wt, Has boon knpementd ad on gang ‘recon. Gre was rot ana thachent #2" || Proo! traning wi be submited ono belore § | reaued visual oneck every 5 minutes ane |8| me POC date {0 ndested that eter he sdmintrtornote | 1] Region! Director ha adiea hone noes? 12] Kened on tre PP tor any clans Thi ack |! fl efkroweage of St on clon #2 kentiod ("3 [g] neede and sorvice reauteain cient 42 not Being chockes ever 15 minutos while se waa aslogp. This a Type A dolincy as the health ane sty ean #2 wan laced n Imminent ange. +1] Personne Requirement. Fecity personnel || Ate the nin, mesa changes wore 2| stall competent to povce to sews || implemented to aig stating wt ie needs of Type 5 | necessary to meet indica tent noes anc || ne chets per tnt iP atte acy razizo17 |) shal ata ines, be employed n numbers |3| Program Design (e911 rto) Implemented seeton ced $] rceesary tome such noes. 4) anelectonic chock nsyton for ovorght ‘con a 3 | stat: Lense aprood to suomi a copy of stat wos [S| $]Scnedl orie month ot one 017, 35 pro th require plan of opeaton, Tense sated thal at ight re wl Bo two 8 awake drect uppon professionals (OSP}on | 3 iy and one overnight stall rendy 0 work | 10] cad (on cas). Lane hc oy echoes | 11 one OSP on diy between TOPM and GAM on 1 12 Nay t4,2017 wen the stabing nent | 7 4 13) occured a spproximatey S48a4 The [3 "4 nian cash bean sve nee wre [a "Wo awake OSP on ety ath neo he incident Failure to correct the cited deficiency(les), on or before the Plan of Correction (POC) due dat a civil penalty assessment. SUPERVISOR'S NAME: Alex Estrada ‘TELEPHONE: (818) 596-4964 LICENSING EVALUATOR NAME: Jose Gary Tan ‘TELEPHONE: (828) 219-1149 LICENSING EVALUATOR SIGNATURE: IS ave: may result in 2721/2017' acknowledge recelpt of this form and understand my appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: : Gx tA DATE: 1221/2017 uct (FA) 0600) Ponte