336403110-10-7-2025-18-AS-RORN-DMGQMW-20251015121813

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 336403110
Report Date: 10/07/2025
Date Signed: 10/07/2025 02:16:04 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
03/15/2022 and conducted by Evaluator Antonine Richard

COMPLAINT CONTROL NUMBER: 18-AS-20220315090350

FACILITY NAME:	SLB INCORPORATED-LYDIA'S HOME		FACILITY NUMBER:	336403110
ADMINISTRATOR:	COTADELA BALATBAT		FACILITY TYPE:	735
ADDRESS:	12871 VELVET LEAF ST.		TELEPHONE:	(951) 243-7507
CITY:	MORENO VALLEY	STATE: CA	ZIP CODE:	92553
CAPACITY:	6	CENSUS: 1	DATE:	10/07/2025
		UNANNOUNCED	TIME BEGAN:	10:12 AM
MET WITH:	Ellen Amante		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Lack of Care and Supervision resulting in client becoming malnourished.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

On October 07, 2025, at approximately 10:10 AM, Licensing Program Analyst (LPA) Antonine Richard conducted an unannounced follow-up complaint visit. LPA Richard met with staff member Mikko Galang and explained the purpose of the visit. Later, LPA Richard was joined by Administrator Ellen Amante.

The Investigation consisted of the following: LPA conducted the following interviews: Administrator (A1), former Administrator (A), the facility (CEO), two staff (S1-S2), one client (C2), and Inland Regional Center Services Coordinator (IRCSC). LPA obtained and reviewed the following documents: Resident Roster, Staff Roster dated 07/01/25. A copy of Client (C1) documents: Face sheet dated: 05/05/21, Admission agreement dated: 05/10/21, Physicians Report for Community Care Facility (ARC) or LIC 602 dated:07/21/21, copy of (C1)’s Physician’s Order: dated 02/28/22, SLB, Incorporated-Lydia’s Home Height/Weight Chart dated: 05/10/21 through 03/06/22, Inland Regional Center Action Report dated: 05/03/22.

Evaluation Report continues LIC 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Antonine Richard
LICENSING EVALUATOR NAME: Antonine Richard
LICENSING EVALUATOR SIGNATURE:	DATE: 10/07/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2025

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 3

Control Number 18-AS-20220315090350

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: 10/07/2025

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Allegation: Lack of Care and Supervision resulting in the client becoming malnourished

The complaint alleged that the facility placed the client on a liquid diet despite their ability to consume solid food, leading to significant weight loss for the client.

On October 7, 2025, at approximately 11:00 AM, LPA Richard reviewed the Physician's Report for Community Care Facility (ARC), also known as LIC 602, for Client 1 (C1). The report, dated July 21, 2021, indicated that C1 should be placed on a special diet. A review of the Physician's Order dated February 28, 2022, specified that C1 should follow a Puree Diet and may have 2 scoops of organic vegan protein powder in 8 ounces of water once a day. LPA also examined C1's weight chart covering the period from December 17, 2021, to March 6, 2022. It was noted that C1's weight has remained unchanged since the initial admission to the facility on 05/10/2021.

On October 7, 2025, at approximately 11:00 AM, Licensing Program Analyst (LPA) Antonine Richard interviewed the former administrator (A). The former administrator stated that the staff adhered to the doctor’s orders when serving clients, particularly those on special diets. According to A, the facility had an abundance of food, ensuring that clients would not be deprived of meals.

At around 11:30 AM on the same day, LPA Richard interviewed the current administrator (A1), who confirmed that a physician had prescribed a pureed diet for a client and that the facility staff only followed this physician's order. Later that day, LPA Richard spoke with the CEO of the facility, who denied the allegations. The CEO explained that the facility maintains a weight chart and conducts weekly weight checks for each client. If a client is found to be losing weight, the facility promptly informs the physician. Which was not the case for C1.

On October 7, 2025, at approximately 11:30 AM, an interview was conducted with facility staff members (S1 and S2). They confirmed that client C1 was on a pureed diet. C1 had no issues with the pureed diet, and if C1 wanted to eat something, it was pureed accordingly. S1 also noted that C1 had difficulty swallowing, and at times, even drinking water posed a challenge for C1.

Report Continued LIC9099C

SUPERVISORS NAME: Antonine Richard
LICENSING EVALUATOR NAME: Antonine Richard
LICENSING EVALUATOR SIGNATURE:	DATE: 10/07/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 18-AS-20220315090350

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: 10/07/2025

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Later, at approximately 11:30 AM on the same day, LPA interviewed the Inland Regional Center Services Coordinator (IRCSC), who stated that C1 was on a pureed diet as per the physician's orders. This decision was made because C1's responsible party did not want a G-Tube to be placed. The client C1 had been removed and transferred to another facility on March 11, 2022. Finally, at approximately 1:20 PM on October 7, 2025, LPA interviewed one client, C2, who expressed happiness living in the facility. Unfortunately, LPA was unable to interview C1, as C1 passed away in 2023.

Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur; therefore, the above-mentioned allegation is found to be UNSUBSTANTIATED.

No deficiencies cited.

An exit interview was conducted, and a copy of this Report was provided to the CEO/Administrator, Michael Hall.

SUPERVISORS NAME: Antonine Richard
LICENSING EVALUATOR NAME: Antonine Richard
LICENSING EVALUATOR SIGNATURE:	DATE: 10/07/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2025

LIC9099 (FAS) - (06/04)

Page: 3 of 3