336408502-11-23-2022-56-AS-NBRN-CLLVU5-20221128154411

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 336408502
Report Date: 11/22/2022
Date Signed: 11/23/2022 10:51:39 AM

Unfounded

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
, CA 92507

This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/18/2022 and conducted by Evaluator Amy Goldenberg

PUBLIC

COMPLAINT CONTROL NUMBER: 56-AS-20221118090620

FACILITY NAME:	CASA MIA		FACILITY NUMBER:	336408502
ADMINISTRATOR:	LILIBETH SAMSON		FACILITY TYPE:	740
ADDRESS:	10650 54TH STREET		TELEPHONE:	(951) 685-9000
CITY:	MIRA LOMA	STATE: CA	ZIP CODE:	91752
CAPACITY:	20	CENSUS: 19	DATE:	11/22/2022
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Lilibeth Sampson, Licensee/Administrator		TIME COMPLETED:	11:15 AM

ALLEGATION(S):

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9

Facility staff do not ensure that resident medication is inaccessible to residents.
Resident is forced to have medicatons dispensed by facility staff.

INVESTIGATION FINDINGS:

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This unannounced visit by Amy Goldenberg, Licensing Program Analyst (LPA), to initiate the 10 day visit to investigate the above-mentioned complaint allegations.

Investigation revealed that R1 does not reside at this address. During this visit LPA learned that this licensee is an operator of a room and board facility at the address located next door where R1 resides.

We have found the complaint allegation is unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. We have therefore dismissed the complaint. A copy of this report is being reviewed with, and furnished to the facility representative.

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Amy Goldenberg	TELEPHONE: (951) 201-3990
LICENSING EVALUATOR SIGNATURE:	DATE: 11/22/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2022

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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