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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331800240
Report Date: 12/15/2022
Date Signed: 12/15/2022 09:30:50 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
07/13/2020 and conducted by Evaluator Ryan Gardner
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20200713141435
FACILITY NAME:PERRY'S RESIDENTIAL FACILITY, INCFACILITY NUMBER:
331800240
ADMINISTRATOR:ADAMS, ANDYFACILITY TYPE:
735
ADDRESS:13141 WINDSONG ROADTELEPHONE:
(951) 455-4114
CITY:MORENO VALLEYSTATE: CAZIP CODE:
92555
CAPACITY:5CENSUS: 4DATE:
12/15/2022
UNANNOUNCEDTIME BEGAN:
09:05 AM
MET WITH:Otira Caldwell- Facility ManagerTIME COMPLETED:
09:40 AM
ALLEGATION(S):
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Facility staff neglect resulted in resident being hospitalized.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Ryan Gardner made an unannounced visit to the facility to conclude and issue findings for the investigation that was initiated on 07/17/2020. LPA stated the purpose of the visit and was granted entry and met with Facility Manager Otira Caldwell.

For allegation, Facility staff neglect resulted in resident being hospitalized:

The investigation was conducted by IB Investigator Gina Tallagua which included a review of the client records, facility records, and medical records. The investigation also included interviews with staff and clients.

Based on interviews conducted, and information, and evidence obtained, the IB Investigator found that staff asked Client (C1) multiple times to come inside the home. C1 refused to come inside the home and informed staff that C1 wanted to stay outside. Clients also reported that C1 refused to come inside the home after being asked several times by staff. While C1 was outside, the staff was checking on C1 every five (5) minutes or so. On the last check, the staff realized C1 was unconscious, brought C1 inside the home, and immediately called 911.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Ryan Gardner
LICENSING EVALUATOR SIGNATURE:

DATE: 12/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2022
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-20200713141435
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: PERRY'S RESIDENTIAL FACILITY, INC
FACILITY NUMBER: 331800240
VISIT DATE: 12/15/2022
NARRATIVE
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Based on the information found during the investigation, the allegation listed above is deemed UNSUBSTANTIATED.

A finding that the complaint is UNSUBSTANTIATED means 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.

During today’s visit, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations.

An exit interview was conducted, and this report was discussed and provided to Facility Manager Otira Caldwell, along with a copy of the appeal rights.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Ryan Gardner
LICENSING EVALUATOR SIGNATURE:

DATE: 12/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2