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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 330910676
Report Date: 10/26/2021
Date Signed: 10/27/2021 10:57:08 AM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/21/2021 and conducted by Evaluator Amy Goldenberg
COMPLAINT CONTROL NUMBER: 18-AS-20211021133818
FACILITY NAME:J & S BOARD & CAREFACILITY NUMBER:
330910676
ADMINISTRATOR:SUSAN PRIORFACILITY TYPE:
735
ADDRESS:11334 58TH STREETTELEPHONE:
(951) 360-1287
CITY:MIRA LOMASTATE: CAZIP CODE:
91752
CAPACITY:6CENSUS: 4DATE:
10/26/2021
UNANNOUNCEDTIME BEGAN:
12:37 PM
MET WITH:Susan Prior, Licensee
Karina Crumbley, Caregiver		TIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Lack of supervision
INVESTIGATION FINDINGS:
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13
Licensing Program Analyst (LPA) Amy Goldenberg arrived to the facility unannounced to initiate investigation into the allegation mentioned above. LPA met with Susan Prior, Administrator/Licensee and Caregiver Karina Crumbley to discussed the elements of the allegation.

During this investigation visit LPA requested to review the individual program plans for four (4) residents and interviewed three (3) of four (4) residents residing in the home. LPA learned the following: Review of the Individual Program Plan revealed that four (4) out of four (4) clients do not require supervision in the community. R1, R2, R3 were interviewed and understood that walking on the freeway is unsafe. All three (3) deny having ever walked on the freeway. R4 was not interviewed, however, review of observation notes indicate that R4 has not been without an escort in the community since 08/28/2021.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amy Goldenberg
LICENSING EVALUATOR SIGNATURE:

DATE: 10/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2021
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 18-AS-20211021133818
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: J & S BOARD & CARE
FACILITY NUMBER: 330910676
VISIT DATE: 10/26/2021
NARRATIVE
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Based on the evidence available this agency has found the complaint allegation is unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. A copy of this report is being reviewed with and furnished to the facility representative.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amy Goldenberg
LICENSING EVALUATOR SIGNATURE:

DATE: 10/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 2