331880768-1-10-2025-18-AS-JDHS-DD7PZC-20250123104517

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 331880768
Report Date: 01/10/2025
Date Signed: 01/10/2025 04:03:58 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
12/23/2024 and conducted by Evaluator Kathleen Banrasavong

COMPLAINT CONTROL NUMBER: 18-AS-20241223161130

FACILITY NAME:	PINE CREEK CARE SERVICES		FACILITY NUMBER:	331880768
ADMINISTRATOR:	DAVIS, CHRIS		FACILITY TYPE:	735
ADDRESS:	38203 PINE CREEK PLACE		TELEPHONE:	(951) 319-6374
CITY:	MURRIETA	STATE: CA	ZIP CODE:	92562
CAPACITY:	4	CENSUS: 2	DATE:	01/10/2025
		UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Licensee/Administrator, Chris Davis		TIME COMPLETED:	04:15 PM

ALLEGATION(S):

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Staff engaged in inappropriate behavior toward a resident in care

INVESTIGATION FINDINGS:

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Licensing Program Analyst, (LPA) Kathleen Banrasavong, conducted an unannounced visit to deliver findings for a complaint investigation regarding the above allegation. LPA met with Licensee/Administrator, Chris Davis, where the LPA explained the purpose of the visit and the elements of the allegations. The investigation consisted of observations, interviews with staff members and residents, and a review of records.

On December 23, 2024, Community Care Licensing received a complaint alleging that staff engaged in inappropriate behavior toward a resident in care. The complaint alleged that Staff 1 (S1) provided alcohol to Resident 1 (R1) and Resident 2 (R2). Information obtained from Administrator stated that they received information from R1 that S1 provided alcohol to R1. Administrator advised that S1 was terminated for violating company policy. Additionally, he terminated Staff 2 (S2) and Staff 3(S3) for being in violation of company policy for knowing about the incident and not reporting it to him. LPA interviewed residents and residents denied S1 provided them alcohol. This information contradicts the information provided by the Administrator.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Kathleen Banrasavong
LICENSING EVALUATOR SIGNATURE:	DATE: 01/10/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2025

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-20241223161130

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: PINE CREEK CARE SERVICES	FACILITY NUMBER: 331880768
	VISIT DATE: 01/10/2025

NARRATIVE

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During the course of the investigation, LPA was unable to reach additional pertinent parties. Due to the LPA being unable to interview all pertinent parties, the allegation that staff engaged in inappropriate behavior toward a resident in care is unsubstantiated.

Based on the information obtained during the investigation, this agency has investigated the complaint that staff engaged in inappropriate behavior toward a resident in care. Although the allegations may have occurred or be valid, there is not a preponderance of evidence to prove that the alleged violations did or did not occur. Therefore, the allegations are unsubstantiated.

An exit interview was conducted, and a copy of this report was discussed with and provided to Administrator, Chris Davis.

SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Kathleen Banrasavong
LICENSING EVALUATOR SIGNATURE:	DATE: 01/10/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2025

LIC9099 (FAS) - (06/04)

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