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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 336403110
Report Date: 04/17/2025
Date Signed: 04/17/2025 02:06:18 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/14/2021 and conducted by Evaluator Paola Guerrero
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20210114163653
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:
04/17/2025
UNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Michael Hall (CEO)TIME COMPLETED:
02:15 PM
ALLEGATION(S):
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Staff neglect resulted in resident becoming dehydrated.
Staff neglect resulted in resident sustaining and infection.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Paola Guerrero conducted an unannounced visit to deliver findings on the allegations listed above. LPA met with Facility Administrator (CEO) Michael Hall and explained the purpose of the visit. The investigation consisted of interviews, observations, and review of records.

First allegation: Staff neglect resulted in resident becoming dehydrated. Regarding the allegation stated above LPA conducted a file review of Client #1 records. During the review of records LPA was not able to obtain records that indicated that Client #1 became dehydrated. After further review of records, LPA discovered that Client#1 was transported to local hospital on 10/22/2020, due to low blood pressure. In addition, LPA discovered that on 1/10/2021 Client #1 was transported to local hospital due to the discovery of redness found on Client #1 G-tube. No record reporting dehydration for Client #1 was found.

Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Paola Guerrero
LICENSING EVALUATOR SIGNATURE:

DATE: 04/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2025
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-20210114163653
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA
FACILITY NAME: SLB INCORPORATED-LYDIA'S HOME
FACILITY NUMBER: 336403110
VISIT DATE: 04/17/2025
NARRATIVE
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Second allegation: Staff neglect resulted in resident sustaining and infection. Regarding the allegation stated above LPA conducted a file review of Client #1 records. During the review of records LPA discovered that Client#1 was transported to local hospital on 1/10/2021 due to the discovery of redness found around Client #1 G-tube. Documentation further explained that no leak was found however, medication (Nystatin cream), was prescribed to treat Client#1 skin infection, records also indicated that Client#1 was discharged from local hospital on the same day 1/10/2021. In addition, during the review of record LPA discovered that facility had a restricted health plan on file that was signed and approved by physician. In addition, LPA also observed an exception for Client #1 to be on file. Based on corroborating evidence obtained during the course of the investigation, LPA has determined that the above allegation is Unsubstantiated.

Unsubstantiated: meaning that 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 where this report (LIC 9099) was discussed, and a copy was provided to Facility Administrator (CEO) Michael Hall.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Paola Guerrero
LICENSING EVALUATOR SIGNATURE:

DATE: 04/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2