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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331880747
Report Date: 11/19/2025
Date Signed: 11/19/2025 02:49:23 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 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
07/27/2023 and conducted by Evaluator Antonine Richard
COMPLAINT CONTROL NUMBER: 18-AS-20230727122844
FACILITY NAME:CHIHUAHUA HOMEFACILITY NUMBER:
331880747
ADMINISTRATOR:SHAYLA RODRIGUEZFACILITY TYPE:
735
ADDRESS:77595 CALLE CHIHUAHUATELEPHONE:
(442) 256-4174
CITY:LA QUINTASTATE: CAZIP CODE:
92253
CAPACITY:4CENSUS: 3DATE:
11/19/2025
UNANNOUNCEDTIME BEGAN:
11:11 AM
MET WITH:Rosa LopezTIME COMPLETED:
03:10 PM
ALLEGATION(S):
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Facility do not have adequate staffing to care and supervise resident.
INVESTIGATION FINDINGS:
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On November 19, 2025, Licensing Program Analyst (LPA) Antonine Richard conducted a subsequent visit and delivered findings. LPA met with the Assistant Administrator (A2), Rosa Lopez, and the purpose of the visit was explained. The investigation included the following: On November 19, 2025, at approximately 11:30 am, the LPA Richard requested and reviewed the following documents: the client roster (dated 09/06/2024) and the staff roster (dated 10/09/2025). The LPA reviewed and collected the Resident (R1) Admission Agreement (dated 06/23/2023), the Individual Program Plan (IPP) dated 08/04/2022, Physician Orders (dated 06/28/23 and 07/06/23), the Physical Psychiatric Evaluation (dated 06/28/23), Medication Administration Records (MARs) dated 07/31/23), Inland Regional Center Special Incident Reports (SIR) dated 07/15/23 and 07/20/23), facility notes (dated 07/17/23 and 07/20/23), and the R1 Consumer Transfer/Discharge Inventory Sheet (dated 07/21/23). The LPA received an email from the Licensee (dated 07/25/23), sent by the Consumer Service Coordinator. On November 19, 2025, at approximately 11:30 AM, the LPA interviewed the Administrator (A1), the Assistant Administrator (A2), three staff members (S1-S3), and three clients (C2-C4). The LPA was unable to interview C1 because C1 no longer resides at the facility.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Antonine Richard
LICENSING EVALUATOR NAME: Antonine Richard
LICENSING EVALUATOR SIGNATURE:

DATE: 11/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2025
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 18-AS-20230727122844
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: CHIHUAHUA HOME
FACILITY NUMBER: 331880747
VISIT DATE: 11/19/2025
NARRATIVE
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Allegation: Facility do not have adequate staffing to care and supervise residents.

The complaint alleged that the facility lacked adequate staffing to care for and supervise residents due to three staff members having quit. On November 19, 2025, the Licensing Program Analyst (LPA) Richard interviewed the Administrator A1, who denied the allegation and stated that the facility has sufficient staff to care for the clients, even if some staff leave. The LPA also interviewed the Assistant Administrator A2, who indicated that they had quit after Client C1 became physically aggressive toward staff members, but returned once C1 was no longer living at the facility.

Additionally, the LPA interviewed three staff members (S1, S2, and S3), all of whom denied the allegation and asserted that there are plenty of staff available to replace anyone who decides to leave. The LPA also interviewed three Clients (C2-C4), who expressed satisfaction with living at the facility and stated that the staff treated them well.

Furthermore, on November 19, 2025, the LPA reviewed a document from John F. Kennedy Memorial Hospital (dated July 19, 2023), which indicated that Client C1 was admitted under a 5150 hold and did not return to the facility after discharge. The conservator requested via email that the service be terminated.

Report continued on LIC9099C

SUPERVISORS NAME: Antonine Richard
LICENSING EVALUATOR NAME: Antonine Richard
LICENSING EVALUATOR SIGNATURE:

DATE: 11/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 18-AS-20230727122844
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: CHIHUAHUA HOME
FACILITY NUMBER: 331880747
VISIT DATE: 11/19/2025
NARRATIVE
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Based on the interview, the records, and the information reviewed, there was insufficient evidence to support the allegation. 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; therefore, the allegation is deemed unsubstantiated.

No deficiencies cited.

An exit interview was conducted. A copy of this report was provided to the Assistant Administrator, Rosa Lopez.

SUPERVISORS NAME: Antonine Richard
LICENSING EVALUATOR NAME: Antonine Richard
LICENSING EVALUATOR SIGNATURE:

DATE: 11/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3