331800454-8-10-2022-18-AS-TDAN-DB62PG-20241118163415

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 331800454
Report Date: 08/10/2022
Date Signed: 08/10/2022 04:39:12 PM

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
08/02/2022 and conducted by Evaluator Janira Arreola

COMPLAINT CONTROL NUMBER: 18-AS-20220802091711

FACILITY NAME:	FAITHWORKS RESIDENTIAL HOMES		FACILITY NUMBER:	331800454
ADMINISTRATOR:	GROVE, ZENOBIA		FACILITY TYPE:	735
ADDRESS:	31922 BAY LAUREL STREET		TELEPHONE:	(951) 430-1429
CITY:	MENIFEE	STATE: CA	ZIP CODE:	92584
CAPACITY:	4	CENSUS: 4	DATE:	08/10/2022
		UNANNOUNCED	TIME BEGAN:	12:41 PM
MET WITH:	Administrator, Zenobia Grove		TIME COMPLETED:	04:45 PM

ALLEGATION(S):

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Resident sustained injuries while in care.
Facility did not assist resident with medical transportation.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Janira Arreola made an unannounced visit to the facility to initiate an investigation into the above allegations. LPA met with administrator, Zenobia Grove, who was informed of the purpose of the visit.

At the time of the visit ther were (5) staff and (4) residents present. LPA gathered and reviewed pertainant documents such as resident roster, staff roster, and resident incident reports, care plan, and phsyican's report. Concerning the first allegation "Resident sustained injuries while in care" LPA reviewed facility staff interviews, and skin checks conducted that morning and afternoon by the facility. Based on these, there is not enough evidence to suggest that the injury happened while the resident was in the facility's care. Therefore the allegation is unsubstantiated.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Joel Esquivel	TELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Janira Arreola	TELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:	DATE: 08/10/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 18-AS-20220802091711

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: FAITHWORKS RESIDENTIAL HOMES	FACILITY NUMBER: 331800454
	VISIT DATE: 08/10/2022

NARRATIVE

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Concerning the second allegation "Facility did not assist resident with medical transportation." LPA conducted staff interviews with those witnesses from the facility. LPA also reviewed medical records obtained from the incident date and found that Client 1 (C1) was taken to the hospital when the incident occurred. Therefore, the allegation is unsubstantiated.

Both allegations reached a finding of unsubstantiated. A finsing of unsubstantiated means that the preponderance of the evidence standard has not been met in order to suggest that the allegation did occur.

No deficiencies were cited at the time of the visit. LPA will document technical viloation on LIC9102TV Concerning reporting requirements for the incident.

An exit interview was conducted with Administrator, Zenobia Grove over the phone and staff Danielle Mitchell in person, were this report was read out and reviewed. LPA had staff Danielle Mitchell sign the report and provide a physical copy to her.

SUPERVISOR'S NAME: Joel Esquivel	TELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Janira Arreola	TELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:	DATE: 08/10/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2022

LIC9099 (FAS) - (06/04)

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