331881043-3-14-2024-56-AS-EMAN-D3HTSX-20240319145952

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 331881043
Report Date: 03/14/2024
Date Signed: 03/14/2024 01:15:56 PM

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
01/05/2024 and conducted by Evaluator Ryan Gardner

PUBLIC

COMPLAINT CONTROL NUMBER: 56-AS-20240105100250

FACILITY NAME:	NOAH'S ARK ADULT HOME		FACILITY NUMBER:	331881043
ADMINISTRATOR:	ANGUIANO, RUTH		FACILITY TYPE:	735
ADDRESS:	20094 KLYNE ST.		TELEPHONE:	(951) 707-6803
CITY:	CORONA	STATE: CA	ZIP CODE:	92881
CAPACITY:	4	CENSUS: 2	DATE:	03/14/2024
		UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Ruth Anguiano- Administrator		TIME COMPLETED:	01:20 PM

ALLEGATION(S):

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Resident sustained unexplained injuries while in care.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Ryan Gardner made an unannounced visit to deliver findings for the allegation listed above. LPA stated the purpose of the visit, was granted entry, and met with Administrator Ruth Anguiano. The investigation consisted of client interviews, staff interviews, and document review.

For allegation, Resident sustained unexplained injuries while in care: It was alleged that Client C1 sustained a hand injury while in care.

Interviews with the staff revealed that there was no known injury to C1’s hand. Interviews revealed that C1 had an ongoing rash on their hand. The rash would flare up, get dry, get red, have minor bleeding, and get chapped during cold weather. The staff denied hurting C1’s hand. The staff denied that another client in the home injured C1’s hand. The staff stated that the redness on C1’s hand was due to an ongoing rash. The staff stated that they were told by C1 that C1 fell and injured their hand while they were alone in the backyard. The staff denied that C1 fell in the backyard.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Ryan Gardner
LICENSING EVALUATOR SIGNATURE:	DATE: 03/14/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2024

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 56-AS-20240105100250

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: NOAH'S ARK ADULT HOME	FACILITY NUMBER: 331881043
	VISIT DATE: 03/14/2024

NARRATIVE

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If C1 is in the backyard, the staff would be present to supervise C1. If C1 fell in the backyard, the staff would have witnessed the fall and helped C1.

Interviews with the clients revealed that the clients have never been injured by the staff. The clients denied that staff have ever hurt them. The clients denied that other clients in the home have hurt them. C1 stated that they fell outside in the backyard on an unknown date and landed on their hand. C1 stated there were no witnesses present in the backyard to see them fall. Additionally, C1 stated that it is normal for their hands to get dry and hurt when the weather is cold. When C1’s hand hurts, the staff applies a cream for relief.

A document review of C1’s medication record (MAR) revealed that C1 has a current prescription for an ointment.

Overall, there was not enough evidence to collaborate the allegation listed above.

Based on evidence obtained 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 (LIC9099) was discussed and provided Administrator Ruth Anguiano, along with a copy of the appeal rights.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Ryan Gardner
LICENSING EVALUATOR SIGNATURE:	DATE: 03/14/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2024

LIC9099 (FAS) - (06/04)

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