331881302-3-7-2025-56-AS-EMAN-DEYT9X-20250321143240

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 331881302
Report Date: 03/07/2025
Date Signed: 03/07/2025 02:09:36 PM

Unsubstantiated

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
01/31/2025 and conducted by Evaluator Melody Brown

PUBLIC

COMPLAINT CONTROL NUMBER: 56-AS-20250131082802

FACILITY NAME:	PASSIONATE HOME 1		FACILITY NUMBER:	331881302
ADMINISTRATOR:	FADIPE, SUNDAY D.		FACILITY TYPE:	735
ADDRESS:	29340 GRAND SLAM		TELEPHONE:	(323) 671-6789
CITY:	LAKE ELSINORE	STATE: CA	ZIP CODE:	92530
CAPACITY:	4	CENSUS: 3	DATE:	03/07/2025
		UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Licensee/Administrator Olajumoke Ijabadenuyi		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Staff inappropriately restrained client.
Client in care sustained unexplained injury.

INVESTIGATION FINDINGS:

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On 03/07/2025 at 01:30 PM, Licensing Program Analyst (LPA) Melody Brown, met with Licensee/Administrator Olajumoke Ijabadenuyi at Community Care Licensing Division (CCLD) Adult and Senior Care (ASC) San Bernardino Regional Office to deliver the findings of the above allegations. LPA Brown explained the purpose of the requested Office Visit. The investigation consisted of file review, interviews with clients and staffs as well as observation.

First allegation: Staff inappropriately restrained client. The investigation was conducted by LPA Melody Brown which consisted of observation and interviews with relevant parties. The first allegation indicates that staff inappropriately restrained client. During the investigation, LPA Brown was not able to obtain sufficient evidence to corroborate the allegation. LPA Brown interviewed Client #2 (C2) and C2 indicated that staffs at the facility are not restraining them. C2 stated that there's no incident that happened at the facility that a staff inappropriately restrained Client #1 (C1) or any other clients at the facility. LPA Brown unable to interview C1 as C1's unable to answer LPA Brown's questions. Interview with four (4) of ***Continuation in LIC9099C***

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE:	DATE: 03/07/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2025

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 3

Control Number 56-AS-20250131082802

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: PASSIONATE HOME 1	FACILITY NUMBER: 331881302
	VISIT DATE: 03/07/2025

NARRATIVE

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four (4) staffs indicated that they did not inappropriately restrain C1. Four (4) of four (4) staff interviewed revealed that on 01/29/2025, they did not inappropriately restrain C1. Three (3) of three (3) staff interviewed reported that no restrained was conducted on 01/29/2025 when C1 was on video call with C1's physician as they just redirected C1. During the facility visit on 02/03/2025, LPA Brown witnessed C1 agitated, exhibited aggressive behavior to C2 and observed Staff #3 (S3) and Staff #4 (S4) redirected C1 with Staff #1 (S1) assistance. Moreover, LPA Brown noted that S3. S4 and S1 were not rough when they were redirecting C1. C1's Inland Regional Center (IRC) Consumer Services Coordinator (CSC) informed LPA Brown that they are aware of C1's disruptive behaviors, aggression towards others, self-injury, destruction of property, wandering away and emotional outbursts. C1's IRC CSC added that staffs at the facility were aware that they will only conduct CPI if there's a danger to C1 or towards them. Also, per documents review, LPA Brown observed that four (4) of four (4) staffs at the facility have updated emergency intervention (CPI) certification maintained in their facility file.

Second allegation: Client in care sustained unexplained injury. The investigation was conducted by LPA Melody Brown which consisted of file review, observation and interviews with relevant parties. During the investigation, LPA Brown was not able to obtain sufficient evidence to support that client in care sustained unexplained injury. LPA Brown interviewed C2 and C2 stated that C2 was not aware of a client in care that sustained unexplained injury at the facility. C2 reported that there's no incident that C2 observed C1 sustained unexplained injury. LPA Brown unable to interview C1 as C1's unable to answer LPA Brown's questions. Four (4) of four (4) staff interviewed denied that C1 sustained unexplained injury while in care at the facility. Four (4) of four (4) staff interviewed reported that C1 arrived at the facility from the hospital on 11/2024 with bruises on face, arms, hands, legs. Four (4) of four (4) staff interviewed shared that they took a picture of C1's bruises when C1 arrived from the hospital on 11/2024 and they informed C1's Inland Regional Center (IRC) Consumer Services Coordinator (CSC), family member and Community Care Licensing Division (CCLD). C1's IRC CSC indicated that C1 has a habit of throwing self on the ground, self-injury behavior of biting C1's arm, or scratching self. C1's IRC CSC informed LPA Brown that C1 arrived at the facility with bruises and it did not happen at the facility. During the facility visit on 02/03/2025, LPA Brown observed C1 biting C1's arm and C1 throwing self on the ground.

***Continuation in LIC9099C***

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE:	DATE: 03/07/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 56-AS-20250131082802

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: PASSIONATE HOME 1	FACILITY NUMBER: 331881302
	VISIT DATE: 03/07/2025

NARRATIVE

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Therefore, based on the evidence obtained during LPA Brown's investigation, there is insufficient evidence to prove that staff inappropriately restrained client (Allegation #1), client in care sustained unexplained injury (Allegation #2) are UNSUBSTANTIATED at this time. Although the allegation of staff inappropriately restrained client (Allegation #1), client in care sustained unexplained injury (Allegation #2) 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 allegations are UNSUBSTANTIATED at this time.

An exit interview was conducted where this report (LIC9099), was discussed and provided to Licensee/Administrator Olajumoke Ijabadenuyi.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE:	DATE: 03/07/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2025

LIC9099 (FAS) - (06/04)

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