331881496-4-16-2026-18-AS-APEZ-DTZTLY-20260512145020

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 331881496
Report Date: 04/15/2026
Date Signed: 04/16/2026 08:16:53 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
08/19/2024 and conducted by Evaluator Valerie Flores

COMPLAINT CONTROL NUMBER: 18-AS-20240819155801

FACILITY NAME:	SHORELINE ST HOME LLC		FACILITY NUMBER:	331881496
ADMINISTRATOR:	DATO, MARIEROSE		FACILITY TYPE:	735
ADDRESS:	25830 SHORELINE STREET		TELEPHONE:	(951) 485-3490
CITY:	MORENO VALLEY	STATE: CA	ZIP CODE:	92551
CAPACITY:	4	CENSUS: 4	DATE:	04/15/2026
		UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Direct Support Professional Jen Malig		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Resident sustained unexplained injury

INVESTIGATION FINDINGS:

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On 4/15/2026, Licensing Program Analyst (LPA) Valerie Flores conducted an unannounced visit to the facility for the purpose of delivering the complaint finding into the allegation listed above. LPA Flores met with Direct Support Professional Jen Malig and explained the purpose of the visit. The investigation is summarized as follows:

Information received alleged Resident #1 (R1) sustained unexplained injury. Interview with Witness #1 (W1) reported R1 was transported to the hospital with skin injuries near R1’s buttock area. Interviews conducted with (3) three staff report that R1 was experiencing a behavioral episode after being dropped off from day program. When Staff #2 (S2) attempted to direct R1 back into the facility after being dropped off at the curb in front of the facility, R1 refused to be redirected back into the facility. Staff report that R1 sat on the asphalt of the road in front of the facility. Interview with S2 reported that they attempted to pick R1 off of the ground as it was a very hot summer day, but attempts were unsuccessful.
(Continue to LIC9099C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Valerie Flores
LICENSING EVALUATOR SIGNATURE:	DATE: 04/15/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2026

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-20240819155801

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: SHORELINE ST HOME LLC	FACILITY NUMBER: 331881496
	VISIT DATE: 04/15/2026

NARRATIVE

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(Continuation from LIC9099)

Staff interviews report that Staff #3 (S3) came to assist by getting R1 a wheelchair to assist with transferring R1 back into the facility. Interviews with staff reported that no immediate injuries were observed as a result of the behavioral episode. Interviews with staff report that the following day, S3 was assisting R1 with toileting. When R1 got up from the toilet seat, S3 observed blood and some of R1’s skin stuck to the toilet seat. Upon immediate assessment, S3 observed R1’s skin to be burned with blistering. S3 reported to contact Administrator and R1 was transported to the hospital for assessment. LPA attempted to interview R1 but attempt was unsuccessful due to R1’s cognitive abilities. A review of R1’s care plan does not report there to be any known behaviors.

Therefore, the allegation of resident sustained unexplained injury is deemed unsubstantiated. A finding that the complaint is UNSUBSTANTIATED means 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, therefore the allegations are unsubstantiated at this time.

An exit interview was conducted and a copy of this report was provided to the Administrator.

SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Valerie Flores
LICENSING EVALUATOR SIGNATURE:	DATE: 04/15/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2026

LIC9099 (FAS) - (06/04)

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