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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331881331
Report Date: 05/20/2024
Date Signed: 06/20/2024 10:51:46 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
05/13/2024 and conducted by Evaluator Janette Romero
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20240513124312
FACILITY NAME:ERICA B INDEPENDENT LIVING FACILITYFACILITY NUMBER:
331881331
ADMINISTRATOR:JOHNSON, LA SUNEAFACILITY TYPE:
735
ADDRESS:3656 GINGER STTELEPHONE:
(818) 818-1817
CITY:PERRISSTATE: CAZIP CODE:
92571
CAPACITY:6CENSUS: 4DATE:
05/20/2024
UNANNOUNCEDTIME BEGAN:
08:35 AM
MET WITH:Licensee, Erica Grahmn-BullockTIME COMPLETED:
01:00 PM
ALLEGATION(S):
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9
Staff financially abused resident
INVESTIGATION FINDINGS:
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On 5/20/2024, Licensing Program Analyst (LPA), Janette Romero made an unannounced visit to the facility to investigate the allegation listed above. LPA was greeted and granted entry by Licensee, Erica Grahmn-Bullock who was informed of the purpose of the visit.

It was alleged, Client 1 (C1) previously resided in the facility and moved out in January of 2024. It was further alleged Licensee became C1's representative payee and had been paid C1's benefits after C1 no longer lived in the facility. LPA toured the facility with Licensee, conducted interviews with staff, clients, and outside sources, and reviewed pertinent records.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE:

DATE: 05/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2024
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-20240513124312
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: ERICA B INDEPENDENT LIVING FACILITY
FACILITY NUMBER: 331881331
VISIT DATE: 05/20/2024
NARRATIVE
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During an interview, Licensee reported C1 never lived in the home. LPA conducted a collateral visit to interview the clients currently residing in the facility. Four (4) clients were interviewed and reported C1 has never lived in the home and they have never met or observed C1 in the home. LPA made several attempts to contact C1 for an interview, but was unsuccessful. During the collateral visit, LPA reviewed C1's records and observed the address listed for C1 does not match the facility's address.

This agency has investigated the complaint alleging, "Staff financially abused resident". Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. An exit interview was conducted, and a copy of this report was provided to Licensee.

Note* LPA was off-site from 9:05 a.m. to 12:45 p.m.

* This is an amended report

SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE:

DATE: 05/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2