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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 336403110
Report Date: 05/09/2024
Date Signed: 05/09/2024 02:49:40 PM

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
04/26/2022 and conducted by Evaluator Tricia Danielson
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20220426143639
FACILITY NAME:SLB INCORPORATED-LYDIA'S HOMEFACILITY NUMBER:
336403110
ADMINISTRATOR:COTADELA BALATBATFACILITY TYPE:
735
ADDRESS:12871 VELVET LEAF ST.TELEPHONE:
(951) 243-7507
CITY:MORENO VALLEYSTATE: CAZIP CODE:
92553
CAPACITY:6CENSUS: 6DATE:
05/09/2024
UNANNOUNCEDTIME BEGAN:
02:40 PM
MET WITH:Mikko Galang, CaregiverTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Resident was physically abused by staff while in care, causing injury.
INVESTIGATION FINDINGS:
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Licensing Program Manager (LPM) Tricia Danielson and Licensing Program Analyst (LPA) Janette Romero conducted an unannounced visit to deliver findings for the above allegation. LPM and LPA met with Caregiver Mikko Galang and advised them of the purpose of today's visit. Below is a summary of the findings of the investigation:
On April 28, 2022, the Department received a complaint alleging "Resident was physically abused by staff while in care, causing injury". On 04/23/2022, Resident 1 (R1) was observed by facility to have a large mass on their right leg while showering. R1 was taken to the hospital on 04/23/2022. Medical records dated 04/25/2022 revealed notes that read R1 disclosed they did not want to return to the facility and that facility staff caused the injury.
Medical records dated 04/23/2022 revealed R1 was brought in by ambulance and ambulance staff reported acute mass with no reports of a fall, injury, or trauma. Medical records dated 04/23/2022 further revealed an impression of “hematoma” and “fall from ground level”. Facility staff interviews revealed they denied any recent falls and or injuries while at the facility. (CONTINUED ON LIC9099C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Reyna Lacey
LICENSING EVALUATOR NAME: Tricia Danielson
LICENSING EVALUATOR SIGNATURE:

DATE: 05/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2024
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-20220426143639
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: SLB INCORPORATED-LYDIA'S HOME
FACILITY NUMBER: 336403110
VISIT DATE: 05/09/2024
NARRATIVE
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(CONTINUED FROM LIC9099)
In addition, facility staff stated not seeing any redness or bruising prior to 04/23/2022. Facility record notes revealed no documented falls between 04/02/2022 through 04/22/2022. A review of R1’s Individual Program Plan (IPP) dated 07/14/2021 revealed R1 did have a behavior of “habitual lying” with no further details provided regarding the false allegations. Interview with placement agency staff revealed R1 did not have a history of falls or self injurious behavior. The Department attempted an interview with R1’s roommate but was unsuccessful. R1 was unable to be interviewed.

Therefore, based on interviews conducted, records reviewed, and overall lack of evidence, the allegation is UNSUBSTANTIATED at this time. A finding of 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.

An exit interview was conducted with Galang and a copy of this report and LIC 811 was reviewed and provided.
SUPERVISORS NAME: Reyna Lacey
LICENSING EVALUATOR NAME: Tricia Danielson
LICENSING EVALUATOR SIGNATURE:

DATE: 05/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2024
LIC9099 (FAS) - (06/04)
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