<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331800057
Report Date: 08/09/2024
Date Signed: 08/09/2024 04:07:42 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 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
08/06/2024 and conducted by Evaluator Mary Rico
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20240806152449
FACILITY NAME:LARK RESIDENTIAL HOMEFACILITY NUMBER:
331800057
ADMINISTRATOR:CASTRO, LUDYFACILITY TYPE:
735
ADDRESS:1008 MEADOWVIEW COURTTELEPHONE:
(951) 520-1070
CITY:CORONASTATE: CAZIP CODE:
92880
CAPACITY:5CENSUS: 2DATE:
08/09/2024
UNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Janet ThomasTIME COMPLETED:
04:15 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not treat resident with respect and dignity.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Mary Rico conducted an unannounced visit to investigate and deliver findings on the allegation listed above. LPA met with staff Janet Thomas and explained the purpose of the visit. The investigation consisted of staff interview, and client interviews.

For the allegation, Staff did not treat resident with respect and dignity.

During staff interviews, S1 confirmed they had picked up C1 from Day Program on August 1, 2024, and had made the remarks of S1 having an accident at the facility. S1 stated that a Day Program staff was present when they had made the remarks to C1. S1 did not preserve C1 dignity by humiliating C1 in front of other people.

During client interviews, C1 stated that S1 had humiliate them by sharing an incident that occurred at the facility on August 1, 2024. 2 out of the 3 clients stated S1 was upset they had to clean C1 accident.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Mary Rico
LICENSING EVALUATOR SIGNATURE:

DATE: 08/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2024
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 3
Control Number 56-AS-20240806152449
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: LARK RESIDENTIAL HOME
FACILITY NUMBER: 331800057
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/09/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/12/2024
Section Cited
CCR
80072(3)
1
2
3
4
5
6
7
80072 Personal Rights (3)
To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, ..interference with the daily living functions, including eating, sleeping, or toileting; or withholding of shelter, clothing, medication or aids to physical functioning.
1
2
3
4
5
6
7
Administrator has agreed to train all staff on the regulation cited above and will send LPA a copy of certification.
8
9
10
11
12
13
14
Based on staff and client interviews facility staff did not ensure C1 personal rights to be met, which poses an immediate health, safety or personal rights risk to persons in care.
8
9
10
11
12
13
14
POC due date 8/12/2024
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Mary Rico
LICENSING EVALUATOR SIGNATURE:

DATE: 08/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 56-AS-20240806152449
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: LARK RESIDENTIAL HOME
FACILITY NUMBER: 331800057
VISIT DATE: 08/09/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Based on the evidence gathered during today’s investigation, the one (1) allegation listed above are deemed SUBSTANTIATED. A finding that the complaints are SUBSTANTIATED means that the allegation are valid because the preponderance of evidence the standard has been met.

During today’s visit, one (1) deficiency were cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted, and this report (LIC9099) and LIC9099D was discussed and provided to staff Janet Thomson along with a copy of the appeal rights.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Mary Rico
LICENSING EVALUATOR SIGNATURE:

DATE: 08/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3