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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331880705
Report Date: 01/09/2023
Date Signed: 01/09/2023 10:41:13 AM

Unsubstantiated


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
01/06/2023 and conducted by Evaluator Ryan Gardner
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20230106131003
FACILITY NAME:DIGNITY LIVING REDWOOD HOMEFACILITY NUMBER:
331880705
ADMINISTRATOR:MARBY, RENEEFACILITY TYPE:
735
ADDRESS:971 REDWOOD CTTELEPHONE:
(951) 427-5508
CITY:CORONASTATE: CAZIP CODE:
92879
CAPACITY:4CENSUS: 3DATE:
01/09/2023
UNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Stephanie Lopez- Direct Support StaffTIME COMPLETED:
10:50 AM
ALLEGATION(S):
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Staff hit resident with an object resulting in bruising.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Ryan Gardner conducted an unannounced visit to the facility for the purpose of initiating an investigation and delivering findings for the above complaint allegation. LPA met with Direct Support Staff Stephanie Lopez and explained the reason for the visit.

During today’s visit, LPA toured the facility, reviewed, and requested facility documents for Client C1, interviewed staff members, and interviewed clients.

For allegation, Staff hit resident with an object resulting in bruising:

During client interviews, C1 informed LPA that the bruise did not come from a staff hitting them with an object. LPA was informed by C1 that the bruise occurred through another event not related to staff. During staff interviews, LPA was informed that C1 obtained the bruise during a family outing. C1 was away from the facility from 12/24/2022 to 1/2/2023.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Ryan Gardner
LICENSING EVALUATOR SIGNATURE:

DATE: 01/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2023
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 2
Control Number 56-AS-20230106131003
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: DIGNITY LIVING REDWOOD HOME
FACILITY NUMBER: 331880705
VISIT DATE: 01/09/2023
NARRATIVE
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LPA found no information to collaborate that the bruise was given to C1 by staff.

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 Direct Support Staff Stephanie Lopez, along with a copy of the appeal rights.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Ryan Gardner
LICENSING EVALUATOR SIGNATURE:

DATE: 01/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2