41. Unannounced Visit: Controlled Substances Copy

Hours:    None

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Facility Type: 730/733 (Group Home)

Facility failed to implement their own emergency intervention plan to prevent clients from having access to controlled substances.

Investigation Findings
Licensing Program Analyst (LPA) conducted a follow-up complaint investigation at the above facility for the purpose of delivering complaint investigation findings. LPA met with Administrator on 11/30/18.

LPA conducted the complaint investigation. Facility health and safety inspection conducted on 9/14/18. Client files (C1, C2, see LIC 811 dated 11/30/18) were reviewed on 9/14/18 and 11/29/18. Interviews conducted with reporting party on 9/11/18, County Representative on 10/10/18, co-complainant on 10/12/18, staff (S1, S2, S3) on 9/14/18, staff (S4) on 10/16/18, staff (S5, S6, S7) on 10/19/18, client (C1) on 9/14/18 and 11/8/18 and client (C2) on 11/27/18. Copies of staffing log and needs and services were obtained. County Representative and co-complainant observed clients (C1 and C2) bagging marijuana on the facility grounds and the staff present were aware and did not intervene or contact law enforcement. Staff interviews consistently confirmed that they do not contact law enforcement because they do not respond or do not do anything.

Facility records reviewed showed no documentation of the incident demonstrating staff intervention or law enforcement contact. Due to the above, the allegation is SUBSTANTIATED meaning that the allegation is valid because the preponderance of evidence standard has been met.

Facility cited for violation of California Code of Regulations, Title 22 Division Six, regulation 84322(f)(5) Emergency Intervention Plan. Exit interview conducted and appeal rights provided. Due to a repeat violation within 12 months, an immediate civil penalty is assessed in the amount of $250 and $100 per day until corrected.

Deficiency Type /
Section Number
Type B
Section Cited
Emergency Intervention Plan. Procedures for accessing community emergency services, including, but not limited to, law enforcement, if the use of emergency interventions is not effective or appropriate. This requirement is not met evidenced by:
Based on record review and interviews, the facility staff did not intervene or contact law enforcement to prevent clients from having access to marijuana which poses a potential Health, Safety, or Personal Rights risk to residents in care.
Facility will provide a comprehensive training to all staff to include the use of internal intervention and law enforcement contact when contraband is present and submit proof of training.
Facility shall also submit a written plan enforcing emergency intervention protocols to be followed by staff.


Facility Report


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