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

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331880750
Report Date: 08/24/2021
Date Signed: 08/24/2021 03:57:08 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
07/06/2021 and conducted by Evaluator Deborah Mullen
COMPLAINT CONTROL NUMBER: 18-AS-20210706121831
FACILITY NAME:A SERVANT'S HEART ADULT RESIDENTIAL FACILITYFACILITY NUMBER:
331880750
ADMINISTRATOR:NELSON, SHAWNTAEFACILITY TYPE:
735
ADDRESS:25703 CEDAR RIVER COURTTELEPHONE:
(951) 672-2270
CITY:MENIFEESTATE: CAZIP CODE:
92585
CAPACITY:4CENSUS: 3DATE:
08/24/2021
UNANNOUNCEDTIME BEGAN:
03:15 PM
MET WITH:Tanesha Curtis, Facility Manager TIME COMPLETED:
04:10 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Resident was allowed to leave the facility without supervision
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Deborah Mullen delivered the findings of the above allegation. LPA met with Tanesha Curtis, Facility Manager. The Department investigation included interviews with staff and residents as well as a review of resident 1's (R1s) records.

Interview with staff 1 (S1) revealed that on July 4, 2021, R1 and another resident (R2) were given permission by S1 to go on a walk up and down the street, as long as they remained without eye sight of staff. S1 stated when R2 return, R2 reported R1 did not want to come back and had walked off down the street. Staff denied that R1 was allowed to leave without supervision. R1 stated he/she was walking within eye sight of staff but decided to leave because he/she wanted to walk to the mountain. LPA reviewed R1s Individual Program Plan and Physician's Report. A review of these documents provided conflicting information, in that the Physician's Report stated R1 was able to leave the facility alone while the IPP stated R1 required "constant supervision 24 hours a day while in placement."

Based upon interviews conducted and a review of R1s facility file there is not enough evidence to state resident was allowed to leave the facility without supervision. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated at this time. An exit interview was conducted, and a copy of this report was reviewed with and provided to Ms. Curtis.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Deborah Mullen
LICENSING EVALUATOR SIGNATURE:

DATE: 08/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2021
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 1