331881148-9-29-2025-18-AS-RORN-DMAKW3-20251009081513

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 331881148
Report Date: 09/29/2025
Date Signed: 09/29/2025 11:45:58 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
12/09/2022 and conducted by Evaluator Antonine Richard

COMPLAINT CONTROL NUMBER: 18-AS-20221209133243

FACILITY NAME:	LEVI HOME		FACILITY NUMBER:	331881148
ADMINISTRATOR:	GARCIA, JESSE		FACILITY TYPE:	735
ADDRESS:	73463 GUADALUPE AVENUE		TELEPHONE:	(760) 600-7020
CITY:	PALM DESERT	STATE: CA	ZIP CODE:	92260
CAPACITY:	4	CENSUS: 3	DATE:	09/29/2025
		UNANNOUNCED	TIME BEGAN:	08:00 AM
MET WITH:	Sandra Hernandez		TIME COMPLETED:	12:00 PM

ALLEGATION(S):

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Staff do not address a client's change in medical condition.

INVESTIGATION FINDINGS:

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On 09/29/2025 at approximately 8:00 AM, Licensing Program Analyst (LPA) Antonine Richard conducted a subsequent unannounced complaint visit. LPA met the House Manager (HM) Julie Baez, and LPA Richard explained the purpose of this visit.

Investigation consisted of: LPA conducted the following interviews: House Manager (HM) Interview, Client’s Interviews (C2), LPA attempted to interview C3, Staff Interview (S1), and the Administrator (A1). LPA obtained and reviewed the following documents: Client’s Roster dated 7/01/25, Staff Roster dated 9/01/25, a copy of (C1)’s face sheet (dated 09/09/2022), (C1)’s Physicians Report for community Care Facilities (dated 10/03/2022). Resistiveness Intervention Plan (dated 03/2023 through 04/2023 and the Hospital visits (dated 09/23, 10/14, 10/24, 11/16,12/09/2022, and 01/23 and 03/14/2023.

Evaluation Report continues LIC 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Antonine Richard
LICENSING EVALUATOR NAME: Antonine Richard
LICENSING EVALUATOR SIGNATURE:	DATE: 09/29/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2025

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-20221209133243

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: 09/29/2025

NARRATIVE

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Allegation #1: Staff do not address a client's change in medical condition.

The details of the complaint alleged that facility staff did not address (C1)’s change in medical condition.

On September 29, 2025, around 8:00 a.m., during the records review, LPA Richard examined (C1)’s Physician's Report for Community Care Facility, also known as the LIC 602. LPA Richard observed that LIC 602 was completed on October 03, 2022. This annual completion of LIC 602 demonstrates that the facility is complying with Title 22 regulations concerning clients with cognitive difficulties, Mild intellectual Disabilities, and their changing conditions. Additionally, LPA Richard reviewed (C1)’s regular doctor visit appointments dated 09/23/22, 10/14/22, 10/24/22, 11/16/22, 12/09/22, 01/08/23, and 03/14/23.

On September 29, 2025, at approximately 8:10 AM, LPA interviewed the House Manager (HM). HM denied the allegation and stated that when the client (C1) becomes agitated and aggressive, the facility immediately contacts Emergency Medical Services (EMS) to address the client's health condition. Later, at approximately 8:10 AM on the same day, Licensing Program Analyst (LPA) Richard interviewed Client #2 (C2). C2 stated that C2 likes living here, and the staff always helps when C2 needs assistance. At approximately 8:12 AM on September 29, 2025, LPA attempted to interview C3 but was unable to do so.

On September 29, 2025, at approximately 9:47 am, LPA interviewed the Administrator (A1), who denied the allegation and stated that the facility has been working with a Board-Certified Behavior Analyst (BCBA), Behavior Consultant (BH), and Registered Behavior Technician (RBT) to support C1's behavior. A1 also stated that the physician provides orders to address any changes in the clients' conditions.

Report Continued LIC9099C

SUPERVISORS NAME: Antonine Richard
LICENSING EVALUATOR NAME: Antonine Richard
LICENSING EVALUATOR SIGNATURE:	DATE: 09/29/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2025

LIC9099 (FAS) - (06/04)

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Control Number 18-AS-20221209133243

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: 09/29/2025

NARRATIVE

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On September 29, 2025, at approximately 10:00 am, LPA interviewed staff #1 (S1), who also denied the allegation and mentioned that they are aware that the clients are exhibiting increasing behaviors that are not typical. Records reviewed, including the Physician Report (dated 10/03/22), the Resistiveness Intervention Plan (dated 03/2023 through 04/2023), and Hospital Visits (dated 09/23, 10/14, 10/24, 11/16, 12/09/2022, and 01/23 and 03/14/2023), indicated the facility was addressing client C1's change in medical condition through the hospital visits and the need of higher level of care. On 09/29/2025, LPA attempted to interview the POC but was unable to do so. LPA was also unable to interview C1 because C1 moved out of the facility on 05/03/2023.

Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has not been met. 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 above-mentioned allegation is found to be UNSUBSTANTIATED.

No deficiencies cited.

Exit interview conducted. A copy of this report was provided to the Administrator Sandra Hernandez.

SUPERVISORS NAME: Antonine Richard
LICENSING EVALUATOR NAME: Antonine Richard
LICENSING EVALUATOR SIGNATURE:	DATE: 09/29/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2025

LIC9099 (FAS) - (06/04)

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