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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197607398
Report Date: 04/29/2024
Date Signed: 04/29/2024 01:01:44 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/23/2023 and conducted by Evaluator Evelin Rios
COMPLAINT CONTROL NUMBER: 31-AS-20230223143106
FACILITY NAME:VIP ADULT RESIDENTIAL FACILITYFACILITY NUMBER:
197607398
ADMINISTRATOR:TEKOA HUEYFACILITY TYPE:
735
ADDRESS:37636 RUBY LANETELEPHONE:
(661) 533-3986
CITY:PALMDALESTATE: CAZIP CODE:
93552
CAPACITY:6CENSUS: 4DATE:
04/29/2024
UNANNOUNCEDTIME BEGAN:
12:05 PM
MET WITH:Jermarcus Dumas - AdministratorTIME COMPLETED:
01:05 PM
ALLEGATION(S):
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Facility administrator is falsifying facility staff certificate(s) training.
INVESTIGATION FINDINGS:
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On 4/29/2024, Licensing Program Analysts (LPAs) Evelin Rios and Raymond Comer arrived at the facility to conduct a subsequent unannounced complaint visit. Upon arrival, LPA was greeted by current administrator Jermarcus Dumas, staff #1 (S1) and client #1 (C1). LPA conducted an entrance interview, and explained the purpose of the visit. LPAs and and administrator toured the facility. LPAs did not observe any health or safety issues.

Allegation: Facility administrator is falsifying facility staff certificate(s) training. It was alleged that the administrator is falsifying Crisis Prevention Institue (CPI), Direct Support Staff training year 1 (DPS1), and Direct Support Staff Training year 2 (DPS2) certificate(s). To investigate this allegation, LPA Rios conducted an initial complaint visit on 02/28/2023 and from 12:00 p.m. to 1:45 p.m. LPA interviewed house manager, staff #1(S1), reviewed records, obtained copies of staff training certificates for CPI, DPS1 and DSP2.
(Continue to LIC9099-C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
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 2
Control Number 31-AS-20230223143106
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: VIP ADULT RESIDENTIAL FACILITY
FACILITY NUMBER: 197607398
VISIT DATE: 04/29/2024
NARRATIVE
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(Continued from LIC9099)

Interview with house manager and S1 on 02/28/2023 denied the allegation stating they completed their own training. LPA review of training records did not observe copy of certificates to be altered. LPAs review of 12 staff’ records and training certificate on 02/28/2023 for DSP1 and DSP 2 observed training certificates to differ in appearance with how long ago the training was taken compared to training completed in recent years. LPA could not find staff records for name of staff mentioned on complaint. According to administrator on 04/29/2024 staff mentioned to have worked at facility did not always work at this facility but at another facility. The administrator at the time also stated they did not ask staff to send their training certificates in order to alter the certificates and put another staff member's name on the training document. LPA Rios was unsuccessful with attempts to contact staff mentioned on complaint.


Based on the information provided and the records reviewed the allegation is Unsubstantiated at this time. Exit interview conducted and a copy of this report was signed and delivered to administrator.
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
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: 2 of 2