336408124-8-18-2021-18-AS-EMAN-C67QCD-20210824120259

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 336408124
Report Date: 08/18/2021
Date Signed: 08/18/2021 01:17:51 PM

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
11/19/2019 and conducted by Evaluator Jennifer Semin

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20191119135722

FACILITY NAME:	SHELLEY'S HOUSE		FACILITY NUMBER:	336408124
ADMINISTRATOR:	AILEEN L. LOPEZ		FACILITY TYPE:	735
ADDRESS:	186 EAST STREET		TELEPHONE:	(951) 520-1073
CITY:	NORCO	STATE: CA	ZIP CODE:	92860
CAPACITY:	4	CENSUS: 3	DATE:	08/18/2021
		UNANNOUNCED	TIME BEGAN:	12:30 PM
MET WITH:	Marissa Oliverous		TIME COMPLETED:	01:30 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility refrigerator is locked.
Staff failed to administer medication to client

INVESTIGATION FINDINGS:

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

Licensing Program Analyst (LPA) Jennifer Semin conducted an unannounced visit to deliver the findings of the above complaint allegations. LPA met with Marissa Oliverous.
The investigation consisted of interviews with relevant parties and review of pertinent documents.
The first allegation indicates the facility refrigerator is locked. Staff interviews revealed staff deny ever locking the refrigerator. Interviews with Client 1 (C1) revealed that the refrigerator had been locked on several occasions. Interviews with other clients revealed they have never seen the refrigerator locked.
The second allegation indicates staff failed to administer medication to client. Staff interviews revealed that staff administer all client medication according to their physician’s orders. Documents reviewed indicate medication is given according to physician’s order.
Based upon interviews and information gathered, and 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 allegations are UNSUBSTANTIATED at this time.
An exit interview was conducted where this report was discussed and provided to Marissa Oliverous.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Jennifer Semin
LICENSING EVALUATOR SIGNATURE:	DATE: 08/18/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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