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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 336403110
Report Date: 06/05/2026
Date Signed: 06/05/2026 11:19:43 AM

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
02/16/2024 and conducted by Evaluator Antonine Richard
COMPLAINT CONTROL NUMBER: 18-AS-20240216160357
FACILITY NAME:SLB INCORPORATED-LYDIA'S HOMEFACILITY NUMBER:
336403110
ADMINISTRATOR:ELLEN AMANTEFACILITY TYPE:
735
ADDRESS:12871 VELVET LEAF ST.TELEPHONE:
(951) 243-7507
CITY:MORENO VALLEYSTATE: CAZIP CODE:
92553
CAPACITY:6CENSUS: 6DATE:
06/05/2026
UNANNOUNCEDTIME BEGAN:
08:54 AM
MET WITH:Michael HallTIME COMPLETED:
11:45 AM
ALLEGATION(S):
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Client sustained an unexplained injury while in care of the facility.
Staff did not seek medical treatment for resdient in a timely manner.
INVESTIGATION FINDINGS:
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On June 5, 2026, the California Department of Social Services/Community Care Licensing (CDSS/CCL) Licensing Program Analyst (LPA) Antonine Richard conducted an unannounced complaint visit. LPA met with the Executive Director (ED), Michael Hall (A1), and explained the purpose of the visit.

The complaint investigations consisted of the following. On June 4, 2026, the Department obtained various documents, including the Personnel Report LIC 500 (dated 06/01/26) and the Client Roster (dated 06/01/26). The Department reviewed and collected documents for Client 1 (C1), including the Admission Agreement, the physician's report, and the hospital discharge paperwork. The department also reviewed staff training on the client's personal rights and the Unusual Incident Report. The Department interviewed the Executive Director (ED), two staff members (S1 and S2), and two clients (C1 and C2). On June 4 and 5, 2026, the department contacted the Placement Agency (PA).
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Antonine Richard
LICENSING EVALUATOR SIGNATURE:

DATE: 06/05/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/05/2026
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 4
Control Number 18-AS-20240216160357
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: 06/05/2026
NARRATIVE
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Allegation #1: Client sustained an unexplained injury while in care of the facility.

The complaint alleged that the client sustained unexplained bruising. On June 4, 2026, the department interviewed the Executive Director (ED), who denied the allegation. The ED stated that the client (C1) had a small blister on the left index finger but did not know how it occurred.

On the same day, the department also interviewed two staff members (S1 and S2), who denied the allegations. They confirmed that C1 had a blister on the left index finger while using the wheelchair.

The department interviewed two clients, C1 and C2, on the same day. C1 stated that on February 15, 2024, C1 woke up with a small blister on the left index finger and was unsure how it occurred. Initially, C1 mentioned that the blister was not painful; however, the discomfort began after they left the Day Program. Later that day, the facility took C1 to the Emergency Room (ER). A review of the ER discharge papers dated February 15, 2024, indicated that C1 was admitted to the hospital with a boil on the left index finger. Additionally, the department contacted the placement agency, which stated that the Service Coordinator for C1 at the time no longer works there and that no information is available.

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.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Antonine Richard
LICENSING EVALUATOR SIGNATURE:

DATE: 06/05/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/05/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 18-AS-20240216160357
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: 06/05/2026
NARRATIVE
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Allegation #2: Staff did not seek medical treatment for residents in a timely manner.

The complaint alleged that when the staff was informed that the client had bruises, they did not seek medical care for the client in a timely manner. On June 4, 2026, the department interviewed the Executive Director (ED), who denied the allegation and stated that when clients are injured or in pain, the staff would take them to the Emergency room or call Medical Emergency. However, when C1 was in pain, they did. On June 4, 2026, the department interviewed two staff members, S1 and S2, regarding the allegation. Both staff members denied the allegation, explaining that they had asked C1 whether C1 were in pain, to which C1 responded "no" and indicated a desire to go to the Day Program. Later that same day, after picking C1 up from the Day Program, the staff took C1 to the emergency room. C1 was seen by a doctor and released the following day, February 16, 2024.

On June 4, 2026, the department interviewed two clients, C1 and C2. Both clients reported that the staff treats them well. C1 confirmed that the staff took them to the emergency room after returning from the Day Program. C1 also mentioned that C1 initially did not want to go to the emergency room but later agreed.

On June 4, 2026, the department reviewed the Emergency Room (ER), discharge paperwork dated February 15, 2024, which indicated that C1 was admitted to the hospital with a boil on the left index finger. The department also contacted the placement agency, which reported that the Service Coordinator for C1 at the time no longer works there and that no information is available.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Antonine Richard
LICENSING EVALUATOR SIGNATURE:

DATE: 06/05/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/05/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 18-AS-20240216160357
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: 06/05/2026
NARRATIVE
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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.

No deficiencies were cited.

An exit interview was conducted, and a copy was provided by the Executive Director, Michael Hall.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Antonine Richard
LICENSING EVALUATOR SIGNATURE:

DATE: 06/05/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/05/2026
LIC9099 (FAS) - (06/04)
Page: 4 of 4