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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331881148
Report Date: 11/20/2024
Date Signed: 11/20/2024 10:41:04 AM

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
09/19/2022 and conducted by Evaluator Armando Perez
COMPLAINT CONTROL NUMBER: 18-AS-20220919130719
FACILITY NAME:LEVI HOMEFACILITY NUMBER:
331881148
ADMINISTRATOR:GARCIA, JESSEFACILITY TYPE:
735
ADDRESS:73463 GUADALUPE AVENUETELEPHONE:
(760) 600-7020
CITY:PALM DESERTSTATE: CAZIP CODE:
92260
CAPACITY:4CENSUS: 4DATE:
11/20/2024
UNANNOUNCEDTIME BEGAN:
10:20 PM
MET WITH:Administrator Jose GutierrezTIME COMPLETED:
10:50 PM
ALLEGATION(S):
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Client is ingesting foreign items while in care
INVESTIGATION FINDINGS:
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LEVI HOME # 331881148, CC#18-AS-20220919130719
DATE OF COMPLAINT: 09/19/2022

Client is ingesting foreign items while in care due to lack of supervision.

Licensing Program Analyst, (LPA) Armando Perez conducted an unannounced visit to deliver findings for a complaint investigation regarding the above allegation. LPA met with Administrator Jose Gutierrez and explained the purpose of the visit and the elements of the allegation. The investigation consisted of interviews with staff members, residents, and pertinent parties, observation, and records review.

On September 19, 2022, Community Care Licensing received a complaint alleging due to lack of supervision, Client (C1) is ingesting foreign items while in care. It was reported that C1 was transported to the hospital to be medically evaluated on three different occasions due to ingesting items. Information obtained from an interview with Licensee stated that C1 had behavioral incidents and C1 would runaway from staff and quickly grab foreign objects that C1 would ingest. Licensee denied that the facility was not providing adequate care and supervision. Licensee indicated an intervention plan was developed and additional training pertaining to ingesting foreign items was provided to all staff. Administrator indicated that supervision was increased to deter C1 from ingesting items.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Armando Perez
LICENSING EVALUATOR SIGNATURE:

DATE: 11/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2024
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 2
Control Number 18-AS-20220919130719
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: LEVI HOME
FACILITY NUMBER: 331881148
VISIT DATE: 11/20/2024
NARRATIVE
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Information obtained from staff interviews corroborated the information. LPA reviewed documents such as the staff schedules and the review indicated additional staff were scheduled to meet the required 1:1 care for C1 during all shifts. Additionally, staff records show training was conducted and completed by staff regarding PICA Information obtained from additional witnesses indicated that there were no concerns regarding the care and supervision that the facility was providing. LPA attempted to interview C1, but C1 was unable to provide any pertinent information relative to the allegations. LPA also attempted to interview pertinent parties, but was unable to obtain contact.

Based on the information obtained during the investigation and due to the inability to interview pertinent parties, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur. Therefore, the allegation that due to lack of supervision, client is ingesting foreign items while in care, has been deemed as unsubstantiated.

An exit interview was conducted and a copy of this report was discussed with and provided to Administrator Jose Gutierrez.
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Armando Perez
LICENSING EVALUATOR SIGNATURE:

DATE: 11/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2