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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 336408326
Report Date: 09/05/2024
Date Signed: 09/05/2024 04:14:14 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
08/29/2024 and conducted by Evaluator Sara Martinez
COMPLAINT CONTROL NUMBER: 18-AS-20240829161723
FACILITY NAME:SALLY ADULT RESIDENTIALFACILITY NUMBER:
336408326
ADMINISTRATOR:NELSON CASTROFACILITY TYPE:
735
ADDRESS:16350 SALLY LANETELEPHONE:
(951) 800-9079
CITY:RIVERSIDESTATE: CAZIP CODE:
92504
CAPACITY:6CENSUS: 6DATE:
09/05/2024
UNANNOUNCEDTIME BEGAN:
12:50 PM
MET WITH:Lynnette Natalicio - Lead StaffTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Staff are not preventing resident in care from harming other resident(s) in care
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Sara Martinez arrived unannounced to the facility to initiate the investigation into the allegations listed above. LPA met with House Manager Lynnette Natalicio and explained the purpose of the visit. Complaint investigation consisted of a tour of the interior/exterior areas of the facility, interviews with staff and residents, and records review of requested pertinent documents.

Regarding the allegation "Staff are not preventing resident in care from harming other resident(s) in care" it was reported Client One (C1) was being hit by Client Two (C2) and staff are not intervening. Interview with Staff One (S1) reported when C2 is experiencing self harming behaviors or conducting physically aggressive behavior with a client staff redirect C2 away from the other clients. Interview with Staff Two (S2) reported when C2 has an aggressive behavior with clients S2 will separate the clients and talk to the clients to de-escalate the situation. Interview with three (3) clients reported when C2 becomes physically aggressive with the clients staff are always there to intervene. Interview with C1 reported C2 has never caused serious injury or harm to C1, the physical aggression happens at random but staff are there to intervene.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Sara Martinez
LICENSING EVALUATOR SIGNATURE:

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

DATE: 09/05/2024
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 5
Control Number 18-AS-20240829161723
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: SALLY ADULT RESIDENTIAL
FACILITY NUMBER: 336408326
VISIT DATE: 09/05/2024
NARRATIVE
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Record review of C2's Individual Program Plan (IPP) reveals C2 engages in physically aggressive behavior and C2 will hit, punch, kick, and/or throw objects.

Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. An exit interview was conducted, and a copy of this report was provided to Lynnette Natalicio.
SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Sara Martinez
LICENSING EVALUATOR SIGNATURE:

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

DATE: 09/05/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 5
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
08/29/2024 and conducted by Evaluator Sara Martinez
COMPLAINT CONTROL NUMBER: 18-AS-20240829161723

FACILITY NAME:SALLY ADULT RESIDENTIALFACILITY NUMBER:
336408326
ADMINISTRATOR:NELSON CASTROFACILITY TYPE:
735
ADDRESS:16350 SALLY LANETELEPHONE:
(951) 800-9079
CITY:RIVERSIDESTATE: CAZIP CODE:
92504
CAPACITY:6CENSUS: DATE:
09/05/2024
UNANNOUNCEDTIME BEGAN:
12:50 PM
MET WITH:Lynnette Natalicio - Lead StaffTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Staff are not reporting incidents involving resident(s) in care as necessary.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Sara Martinez arrived unannounced to the facility to initiate the investigation into the allegations listed above. LPA met with House Manager Lynnette Natalicio and explained the purpose of the visit. Complaint investigation consisted of a tour of the interior/exterior areas of the facility, interviews with staff and residents, and records review of requested pertinent documents.

Regarding the allegation, “staff are not reporting incidents involving resident(s) in care as necessary”, it was reported staff are not reporting incidents with Client One (C1) and Client Two (C2). Records review of Inland Regional Center (IRC) Special Incident Report (SIR) with an incident date of 08/06/2024 reveals staff are not reporting C2’s physically aggressive behaviors towards C1 and the other clients in care. SIR states “facility does not have specific dates of the aggression that C1 is reporting at this time”. SIR was written and sent to IRC on 08/07/2024. As of 09/05/2024, the Department has not received this SIR from the facility. Records review of facility staff notes for C1 dated 07/02/2024 revealed during a conversation, C2 had hit C1 in the mouth and C1 hit C2 in the head. An SIR regarding this incident was not reported to the Department.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Sara Martinez
LICENSING EVALUATOR SIGNATURE:

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

DATE: 09/05/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 18-AS-20240829161723
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: SALLY ADULT RESIDENTIAL
FACILITY NUMBER: 336408326
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/05/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/13/2024
Section Cited
CCR
80061(b)(1)
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80061 Reporting Requirements (b) Upon the occurrence, during the operation of the facility...a report shall be submitted to licensing agency within seven days following the occurrence of such event. (1) Events reported shall include...:This requirement was not being met as evidenced by:
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Licensee will ensure facility staff are trained in Title 22 reporting requirements for special incidents with clients and incidents that put clients in physical harm. Licensee will conduct training with staff and submit proof of training material and staff sign-in sheet to LPA by the plan of correction date 09/13/2024.
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Based on observation and records review, the Licensee did not ensure SIRs were not being submitted to the Department regarding Client Two (C2) and their physically aggressive outbursts with self-harming and the clients in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Sara Martinez
LICENSING EVALUATOR SIGNATURE:

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

DATE: 09/05/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 18-AS-20240829161723
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: SALLY ADULT RESIDENTIAL
FACILITY NUMBER: 336408326
VISIT DATE: 09/05/2024
NARRATIVE
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Records review of facility staff notes for C2 dated 08/12/2024 revealed C2 had hit C1 on the head during an interaction and C1 hit C2 on C2’s back. An SIR regarding this incident was not reported to the Department.

Based on LPA’s observations and records reviewed, the preponderance of evidence standard has been met, therefore the above allegation(s) is/are found to be substantiated. California Code of Regulations (Title 22, Division 12, Chapter 1), are being cited on the attached LIC 9099 D. An exit interview was conducted, and a copy of this report was provided.
SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Sara Martinez
LICENSING EVALUATOR SIGNATURE:

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

DATE: 09/05/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5