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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603283
Report Date: 04/19/2023
Date Signed: 04/19/2023 02:20:57 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/14/2023 and conducted by Evaluator Angelica Rea
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20230414100017
FACILITY NAME:VICTOR SUNSHINE RESIDENTIAL CAREFACILITY NUMBER:
198603283
ADMINISTRATOR:MORA, VICTOR OLIVER RFACILITY TYPE:
735
ADDRESS:1410 S. RIDLEY AVE.TELEPHONE:
(626) 346-3498
CITY:HACIENDA HEIGHTSSTATE: CAZIP CODE:
91745
CAPACITY:4CENSUS: 3DATE:
04/19/2023
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Victor Mora TIME COMPLETED:
02:45 PM
ALLEGATION(S):
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Facility staff member did not provide adequate supervision to client in care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Angelica Rea conducted another visit in response to the above allegations. On today's visit, LPA met with Administrator, Victor Mora who assisted with today's visit.

Regarding the allegation that: facility staff member did not provide adequate supervision to client in care, the investigation consisted of interview(s) with Administrator, Staff #1, regional center staff, and resident #1. LPA also reviewed resident #1's file. Mr. Mora stated that on 4/9/23, he and resident #1 went to the Cabazon Outlets. He said that while there, resident #1 stated that he needed to go to the restroom, and Mr. Mora took resident #1 to the restroom. Mr. Mora stated that he waited for resident #1 at the nearby food court. Mr. Mora stated that he went back to the restroom about 15 minutes later, and resident #1 was no longer in the restroom. Mr. Mora stated that he alerted the Outlet center security, and a short time later, he received a phone call from a Riverside Police Officer, letting him know that resident #1 was at the police station. Mr. Mora stated that he went to the Riverside Police Station to pick resident #1 up. Administrator stated that he submitted a Special Incident Report to Community Care Licensing.
Substantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Angelica Rea
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/19/2023
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 4
Control Number 28-AS-20230414100017
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: VICTOR SUNSHINE RESIDENTIAL CARE
FACILITY NUMBER: 198603283
VISIT DATE: 04/19/2023
NARRATIVE
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Resident #1 did not corroborate the allegation. Resident #1 initially stated that he did not remember going to the Cabazon Outlet(s), and then later stated that Mr. Mora walked him to the bathroom, and after that they went home.

Based on interviews, observation, and documents review conducted, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Tittle 22, Division 6 and Chapter 1 are being cited.
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Angelica Rea
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/19/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/14/2023 and conducted by Evaluator Angelica Rea
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20230414100017

FACILITY NAME:VICTOR SUNSHINE RESIDENTIAL CAREFACILITY NUMBER:
198603283
ADMINISTRATOR:MORA, VICTOR OLIVER RFACILITY TYPE:
735
ADDRESS:1410 S. RIDLEY AVE.TELEPHONE:
(626) 346-3498
CITY:HACIENDA HEIGHTSSTATE: CAZIP CODE:
91745
CAPACITY:4CENSUS: 3DATE:
04/19/2023
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Victor Mora TIME COMPLETED:
02:45 PM
ALLEGATION(S):
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Facility staff member made an inappropriate comment to client in care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Angelica Rea conducted another visit in response to the above allegations. On today's visit, LPA met with Administrator, Victor Mora who assisted with today's visit.

Regarding the allegation that : facility staff member made an inappropriate comment to client in care, the investigation consisted of interview(s) with Administrator, Staff #1, Regional center staff, Day Program staff, and Resident #1. LPA also reviewed resident #1's file.

Administrator denied making an inappropriate comment to resident #1. Day Program staff stated that Resident #1 told Day Program Staff that Administrator instructed him not to mention what he did over the weekend. Resident #1 stated that he doesn't remember Administrator making an inappropriate comment to him.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Exit interview was conducted and a copy of this report was provided.
Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Angelica Rea
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/19/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 28-AS-20230414100017
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: VICTOR SUNSHINE RESIDENTIAL CARE
FACILITY NUMBER: 198603283
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/19/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/19/2023
Section Cited
CCR
80078(a)
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Responsibility for providing care and supervision. The licensee shall provide care and supervision as necessary to meet the client's needs.

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Administrator will review regulation 80078, and send a written statement to LPA by POC due date stating that he has reviewed the regulation.
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This requirement is not being met as evidenced by : LPA learned that Resident #1 was not provided with necessary supervision while on an outing at the cabazon outlet on 4/9/23. This poses a potential risk to clients in care.

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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Angelica Rea
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/19/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 4