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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331881201
Report Date: 05/23/2023
Date Signed: 05/23/2023 04:21:12 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
05/19/2023 and conducted by Evaluator Jesse Gardner
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20230519135511
FACILITY NAME:CONCEPT FOR LIFE HOME LLCFACILITY NUMBER:
331881201
ADMINISTRATOR:DUPREE, TIFFANYFACILITY TYPE:
735
ADDRESS:25791 FIR AVETELEPHONE:
(323) 921-8391
CITY:MORENO VALLEYSTATE: CAZIP CODE:
92553
CAPACITY:4CENSUS: 4DATE:
05/23/2023
UNANNOUNCEDTIME BEGAN:
01:32 PM
MET WITH:Amanda Ayala, CaregiverTIME COMPLETED:
04:30 PM
ALLEGATION(S):
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Lack of supervision resulted in client being struck by another client.
Staff does not provide client's transportation to medical appointments.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Jesse Gardner arrived unannounced to conduct an investigation into the above allegations. LPA met with Caregiver Amanda Ayala and toured the facility. The Department's investigation consisted of a review of records, and interviews with staff, and clients.

It was alleged that Client One (C1) fears the other individuals living in the home as they fight each other and try to fight with C1 also.

Continued on LIC9099-C.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Jesse Gardner
LICENSING EVALUATOR SIGNATURE:

DATE: 05/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2023
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-20230519135511
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: CONCEPT FOR LIFE HOME LLC
FACILITY NUMBER: 331881201
VISIT DATE: 05/23/2023
NARRATIVE
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LPA conducted record review dated on March 13, 2023, in which LPA found that Client Two (C2) ate C1's pizza from the refridgerator, and C1 told staff about it. Staff and Client interviews revealed that C2 became upset and slapped C1's arm. Staff and Client interviews further revealed that Staff One (S1) was in the vicinity, and immediately redirected C2 away from C1. Client interviews further revealed that staff is with C2 to redirect C2 each time C2 has an emotional outburst causing C2 to be aggressive with other clients. Due to staff being in the vicinity of C2 and able to redirect C2, this allegation was Unsubstantiated.

It was further alleged that staff do not provide transportation to medical appointments. Record review, Interviews with clients and LPA observation, revealed that the facility van is functional and operates without issue. The allegation stemmed from medical appointment's being allegedly cancelled. Interview with staff revealed that appointments are not cancelled by staff, but rather have been cancelled by the providers, and staff are forced to reschedule. Client interviews revealed that C1 is current on their appointments. Thus, this allegation was 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 violation did or did not occur.

An exit interview was conducted where a copy of this report was discussed with and provided to Facility Manager Derrena Frelow.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Jesse Gardner
LICENSING EVALUATOR SIGNATURE:

DATE: 05/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2023
LIC9099 (FAS) - (06/04)
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