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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 336402596
Report Date: 08/16/2024
Date Signed: 08/16/2024 11:05:20 AM

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
10/26/2020 and conducted by Evaluator Javier Prieto
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20201026121511
FACILITY NAME:SLB INCORPORATED-BAMBIFACILITY NUMBER:
336402596
ADMINISTRATOR:FORTAJADA, JAMIELAHFACILITY TYPE:
735
ADDRESS:13331 BAMBI COURTTELEPHONE:
(951) 653-0604
CITY:MORENO VALLEYSTATE: CAZIP CODE:
92553
CAPACITY:6CENSUS: 6DATE:
08/16/2024
UNANNOUNCEDTIME BEGAN:
09:05 AM
MET WITH:Jeffrey Castillo, AdministratorTIME COMPLETED:
11:05 AM
ALLEGATION(S):
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Resident sustained injuries requiring hospitalization from lack of adequate care and supervision.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Javier Prieto and LPA Renese Howell-Small arrived to the facility to conclude a complaint investigation regarding the above allegation. LPA's met with Administrator Castillo and explained the elements of the complaint.

Regarding allegation, resident sustained injuries requiring hospitalization from lack of adequate care and supervision: LPA's made observations of residents in the home, 2:1 ratio. Interview with Administrator Castillo states that the facility is more than sufficiently staffed to meet the clients needs. LPA's were unable to interview resident #1 (R1), in question, due to resident being non-verbal. Administrator was able to provide documentation of R1's propensity to self-harm. Witness #1 (W1), family member states that they are familiar with R1's behaviors, incidents and any visits to a medical facility.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Javier Prieto
LICENSING EVALUATOR SIGNATURE:

DATE: 08/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/16/2024
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-20201026121511
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: SLB INCORPORATED-BAMBI
FACILITY NUMBER: 336402596
VISIT DATE: 08/16/2024
NARRATIVE
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W1 elaborates about staff care for R1, made aware by staff of any injuries or incidents and states that incidents are not due to lack of care and supervision.

Based on the information obtained there is not enough evidence that resident sustained injuries requiring hospitalization from lack of adequate care and supervision. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. 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 allegation is UNSUBSTANTIATED. This report was signed by LPA Prieto, LPA Howell-Small and Administrator Castillo and a copy was left at the facility.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Javier Prieto
LICENSING EVALUATOR SIGNATURE:

DATE: 08/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/16/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2