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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331880771
Report Date: 11/25/2024
Date Signed: 11/25/2024 11:40:03 AM

Substantiated


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
, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/12/2024 and conducted by Evaluator Melody Brown
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20240612131727
FACILITY NAME:NISSI HOUSEFACILITY NUMBER:
331880771
ADMINISTRATOR:KNIGHTEN, CASSANDRAFACILITY TYPE:
735
ADDRESS:12801 EXCELSIOR STTELEPHONE:
(951) 378-3800
CITY:WHITEWATERSTATE: CAZIP CODE:
92282
CAPACITY:4CENSUS: 4DATE:
11/25/2024
UNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Cherron JacksonTIME COMPLETED:
11:45 AM
ALLEGATION(S):
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9
Staff are mismanaging client's medications.
Staff are not meeting client's medical needs.
Facility has foul odor.
INVESTIGATION FINDINGS:
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7
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9
10
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13
On 11/25/2024 at 09:15 AM, Licensing Program Analyst (LPA) Melody Brown made an unannounced visit to the facility to deliver findings for the above allegations. LPA Brown identified herself to Client #2 (C2), who was also informed of the purpose of the visit. LPA Brown contacted Licensee Cassandra Knighten and informed of the visit. Staff Cherron Jackson arrived and LPA Brown discussed the purpose of today’s visit to staff Jackson.

The investigation was conducted by LPA Melody Brown. The investigation consisted of records review and interviews with relevant parties. The allegation indicates that Staff are mismanaging client's medications. LPA Brown obtained evidence to corroborate the allegation. Interview with Staff #2 (S2) indicated that Client #1 (C1) does not take medications. During the facility visit on 06/18/2024, LPA Brown observed C1's blank Medication Administration Record (MAR) for 03/2023, 06/2023, 04/2024 and 05/2024 and LPA Brown did not see any medications of C1 at the facility as well. LPA Brown discussed the issue with Licensee Cassandra Knighten during the facility visit on 06/18/2024. ***Continuation in LIC9099C***
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 11/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/25/2024
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 6
Control Number 56-AS-20240612131727
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
, CA 92507
FACILITY NAME: NISSI HOUSE
FACILITY NUMBER: 331880771
VISIT DATE: 11/25/2024
NARRATIVE
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The second allegation indicates staff are not meeting client's medical needs. Staff #2 (S2) reported to LPA Brown that they have no available information if C1 has a medical appointment with C1's doctor. S2 added that C1 leaves the facility most of the time and comes back anytime C1 prefers. During the facility visit on 06/18/2024, LPA Brown reviewed C1 facility documents and unable to find information that the facility has a plan to ensure that they are helping C1 on meeting C1's medical needs, no records of medical appointments and medical provider visits. While conducting the visit on 06/18/2024, LPA Brown discussed the issue with Licensee Cassandra Knighten.

The third allegation indicates facility has foul odor. LPA Brown obtained evidence to corroborate the allegation. Interviews with S2 confirmed the foul odor at the facility due to the dog at the facility. Interviews with two (2) of two (2) clients indicated the foul odor at the facility were caused by the dog at the facility. During the facility visit on 06/18/2024, LPA Brown observed the fouled odor at the facility and discussed the issue with Licensee Cassandra Knighten.

Based on the information and interviews gathered the allegation Staff are mismanaging client's medications (Allegation #1), Staff are not meeting client's medical needs (Allegation #2), Facility has foul odor (Allegation #3) are SUBSTANTIATED. A finding that the complaint is SUBSTANTIATED means that the allegations are valid because the preponderance of the evidence standard has been met. Please see LIC9099D for deficiencies cited.

An exit interview was conducted where this report (LIC 9099), LIC9099D and Appeal Rights were discussed, and a copies were provided to staff Cherron Jackson at the conclusion of the visit.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 11/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/25/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 56-AS-20240612131727
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
, CA 92507

FACILITY NAME: NISSI HOUSE
FACILITY NUMBER: 331880771
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/25/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/26/2024
Section Cited
CCR
80075(b)
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80075 Health Related Services (b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. This requirement was not met as evidenced by:
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Licensee stated to train all staff on CCR 80075(b) and submit proof to LPA Brown on Plan of Correction (POC) due date.
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Based on observation, interview and record review, the Licensee did not comply with the section cited above by not ensuring that Client #1 (C1) was assisted as needed with C1's self-administration of prescription and non-prescription medications which poses an immediate health, safety, and personal rights risks to clients in care.
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Type A
11/26/2024
Section Cited
CCR
85075(b)
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85075 Health-Related Services (b) The facility shall develop and implement a plan which ensures that assistance is provided to the clients in meeting their medical and dental needs. This requirement was not met as evidenced by:
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Licensee stated to train all staff on CCR 85075(b) and submit proof to LPA Brown on POC due date.
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Based on observation, interview and record review, the Licensee did not comply with the section cited above by not ensuring that the facility has a plan to ensure that they are helping C1 on meeting C1's medical needs which poses an immediate health, safety, and personal rights risks to clients in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 11/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/25/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 56-AS-20240612131727
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
, CA 92507

FACILITY NAME: NISSI HOUSE
FACILITY NUMBER: 331880771
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/25/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/06/2024
Section Cited
CCR
80072(a)(2)
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7
80072 Personal Rights (a) Except for children’s residential facilities, each client shall have personal rights which include, but are not limited to, the following: (2) To be accorded safe, healthful, and comfortable accommodations... This requirement was not met as evidenced by:
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Licensee stated that they will make sure to maintain the carpets clean at the facility and not have a foul odor and submit proof of Staff Cleaning Schedule to LPA Brown on Plan of Correction (POC) due date.
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Based on observation, interview and record review, the Licensee did not comply with the section cited above by not ensuring that the clients at the facility have comfortable accommodations and not have foul odor at the facility which poses a potential health, safety, and personal rights risks to clients in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 11/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/25/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 6
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
, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/12/2024 and conducted by Evaluator Melody Brown
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20240612131727

FACILITY NAME:NISSI HOUSEFACILITY NUMBER:
331880771
ADMINISTRATOR:KNIGHTEN, CASSANDRAFACILITY TYPE:
735
ADDRESS:12801 EXCELSIOR STTELEPHONE:
(951) 378-3800
CITY:WHITEWATERSTATE: CAZIP CODE:
92282
CAPACITY:4CENSUS: 4DATE:
11/25/2024
UNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Cherron JacksonTIME COMPLETED:
11:45 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff does not ensure that client's room is cleaned.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 11/25/2024 at 09:15 AM, Licensing Program Analyst (LPA) Melody Brown made an unannounced visit to the facility to deliver findings for the above allegation. LPA Brown identified herself to Client #2 (C2), who was also informed of the purpose of the visit. LPA Brown contacted Licensee Cassandra Knighten and informed of the visit. Staff Cherron Jackson arrived and LPA Brown discussed the purpose of today’s visit to staff Jackson.

The investigation was conducted by LPA Brown. The investigation consisted of file review and interviews with relevant parties. The allegation indicates Staff does not ensure that client's room is cleaned. During the investigation, LPA Brown did not find evidence to corroborate the allegation. Interviews with two (2) of two (2) clients indicated that staffs at the facility are ensuring that their rooms are clean. Interview with Staff #2 (S2) indicated that staffs at the facility are ensuring that all their client’s room are clean and there is no incident that they did not ensure that their client’s room are clean. . ***Continuation in LIC9099C***
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 11/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/25/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 56-AS-20240612131727
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
, CA 92507
FACILITY NAME: NISSI HOUSE
FACILITY NUMBER: 331880771
VISIT DATE: 11/25/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
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14
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During the facility visit on 06/18/2024, LPA Brown toured the facility and observed client’s room clean.

Based on interviews and observation, the allegation staff does not ensure that client's room is cleaned is UNSUBSTANTIATED. A finding of unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur.

An exit interview was conducted, where this report (LIC9099) was discussed and provided to Cherron Jackson.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 11/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/25/2024
LIC9099 (FAS) - (06/04)
Page: 6 of 6