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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331881496
Report Date: 05/19/2026
Date Signed: 05/19/2026 03:49:28 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
RIVERSIDE, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/26/2026 and conducted by Evaluator Venus Mixson
COMPLAINT CONTROL NUMBER: 18-AS-20260226150820
FACILITY NAME:SHORELINE ST HOME LLCFACILITY NUMBER:
331881496
ADMINISTRATOR:DATO, MARIEROSEFACILITY TYPE:
735
ADDRESS:25830 SHORELINE STREETTELEPHONE:
(951) 485-3490
CITY:MORENO VALLEYSTATE: CAZIP CODE:
92551
CAPACITY:4CENSUS: 4DATE:
05/19/2026
UNANNOUNCEDTIME BEGAN:
02:08 PM
MET WITH:CAREGIVER, LOLITA DEVILLA TIME COMPLETED:
03:58 PM
ALLEGATION(S):
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Staff do not change resident timely resulting in a rash.
Staff didn't provide resident medical care for rash.
INVESTIGATION FINDINGS:
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On May 19, 2026, Licensing Program Analyst (LPA), Venus Mixson arrived unannounced at the facility and met with the Caregiver, Lolita De Villa. LPA explained the reason for the visit was to provide findings for the
complaint investigation. During the investigation, LPA conducted interviews, record reviews, and made observations pertaining to the listed allegations.
On February 26, 2026, Community Care Licensing received a complaint alleging that Staff do not change resident timely resulting in a rash, and Staff didn't provide resident medical care for rash. It was reported that on 02/26/2026, the facility staff brought Resident #1 (R1) into Urgent Care for a rash in the groin area and suspected that R1 had not been changed or had not been adequately taken care of.
When interviewed the Administrator denied the allegation. The Administrator stated R1 still uses the restroom with assistance and does not go in their adult briefs unless there is an accident. The Administrator advised that the facility staff check R1, by asking R1, do they need to use the toilet, and then they check the pull-up to see if it is wet or dry, on a two hour rotation, or as needed, and log that this was done.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Venus Mixson
LICENSING EVALUATOR SIGNATURE:

DATE: 05/19/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2026
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-20260226150820
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
RIVERSIDE, CA 92507
FACILITY NAME: SHORELINE ST HOME LLC
FACILITY NUMBER: 331881496
VISIT DATE: 05/19/2026
NARRATIVE
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Information obtained from Interviews with staff members indicated that R1 does not utilize an adult diaper that is changed when soiled or wet. R1 utilizes adult pull ups and is assisted with toileting. Meaning that they use the toilet and not go in their pull up unless there is an accident. Additional information obtained from staff members indicated that there was not a rash, but scratches, and the scratches were fresh, and still red when R1 was taken to Urgent care. Staff members indicated that they took R1 to Urgent Care immediately due to R1's continual scratching.
When LPA interviewed, R1, they were not able to advise or provide information due to R1 being non-verbal. LPA’s observations revealed that staff members assisted R1 with daily toileting needs and logged the assistance in daily log. There were no observable concerns or encounters with how the staff members attended to meeting the residents toileting needs at the time of the visit. The review of the records confirmed that R1 was not conserved and that they are their own Responsible Party.
Information obtained from interviews with additional residents two (2) of (4) residents indicated there were no worries or challenges with the facility staff being present to assistance with their toileting needs or providing medical care when required.
Information obtained from interview with Witness, Home Health nurse advised that they visited R1 at the facility on 02/27/2026, and that they did assist with the body checks for skin abrasions. The Witness confirmed that they observed R1’s, scratches, and that they believe strongly that it is possible to have been caused as a direct result of R1 scratching the area due to an infection. LPA made numerous attempts to contact and interview additional relevant Witness (other Home Health nurses) to no avail. LPAs review of the records, including four (4) of (4) four of the residents files, established that there were no other residents receiving care from Home Health agency for rashes of any kind, at the time of this investigation. A further review of the records; including R1’s daily progress notes provided by, (Good Samaritan Home Health) verified information obtained from interviews; that R1 was receiving medical attention. Supplementary information obtained from continued record reviews confirmed that the scratches were completely healed as of 04/24/2026, at the time of an extra visit to make accompanying observations. A further review of the medical records indicated that R1 had an infection and mostly led to R1 scratching due to irritation.
Based on information obtained from interviews, record review and observations, the evidence received pertaining to the allegations Staff do not change resident timely resulting in a rash, and Staff didn't provide resident medical care for rash, has been deemed unsubstantiated. An unsubstantiated allegation means although the allegation may have happened or is valid, there is not sufficient evidence to establish that the alleged violations did or did not occur. An exit interview was conducted. A copy of this report was discussed and given to the Caregiver, Lolita De Villa.

SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Venus Mixson
LICENSING EVALUATOR SIGNATURE:

DATE: 05/19/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 2