336408502-12-5-2022-56-AS-NBRN-CMBVHL-20221221152719

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 336408502
Report Date: 12/05/2022
Date Signed: 12/05/2022 02:20:26 PM

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
11/28/2022 and conducted by Evaluator Amy Goldenberg

PUBLIC

COMPLAINT CONTROL NUMBER: 56-AS-20221128115349

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: 17	DATE:	12/05/2022
		UNANNOUNCED	TIME BEGAN:	11:15 AM
MET WITH:	Lilibeth Samson, Licensee		TIME COMPLETED:	02:45 PM

ALLEGATION(S):

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Staff do not keep an adequate food supply.
Staff do not allow resident to have access to the telephone.

INVESTIGATION FINDINGS:

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This unannounced visit by Amy Goldenberg, Licensing Program Analyst (LPA), is to initiate the 10 day visit to investigate the above-mentioned complaint allegations. LPA met with Lilibeth Samson and explained the elements of the allegations.

During the course of the investigation LPA reviewed the facility menu and assessed the food supply. LPA took photographs of the food located in the pantry and in three (3) refrigerator and freezers. Interviews were conducted with four (4) staff. Interviews were conducted with nine (9) of seventeen (17) residents. A review of resident records was completed and copy of pertinent documents obtained. Investigation revealed the following: In regard to the staff do not keep an adequate food supply, LPA tour of the kitchen and review of the food stores and menu refute the allegation. LPA verified supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days are being maintained on the premises.

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: 12/05/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2022

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

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
11/28/2022 and conducted by Evaluator Amy Goldenberg

COMPLAINT CONTROL NUMBER: 56-AS-20221128115349

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:	DATE:	12/05/2022
		UNANNOUNCED	TIME BEGAN:	11:15 AM
MET WITH:	Lilibeth Samson,		TIME COMPLETED:	02:45 PM

ALLEGATION(S):

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9

Staff are verbally abusive to resident.
Staff do not treat resident with dignity and respect.

INVESTIGATION FINDINGS:

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13

This unannounced visit by Amy Goldenberg, Licensing Program Analyst (LPA), is to initiate the 10 day visit to investigate the above-mentioned complaint allegations. LPA met with Lilibeth Samson and explained the elements of the allegations.

During the course of the investigation LPA reviewed the facility menu and assessed the food supply. LPA took photographs of the food located in the pantry and in three (3) refrigerator and freezers. Interviews were conducted with four (4) staff. Interviews were conducted with nine (9) of seventeen (17) residents. A review of resident records was completed and copy of pertinent documents obtained. Investigation revealed the following: In regard to the allegations that staff are verbally abusive to residents and do not treat resident with dignity and respect, eight (8) of nine (9) residents interviewed deny that they have been abused or have not been treated with dignity and respect and report R1 was heard yelling at staff or crying.

Unsubstantiated

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: 12/05/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2022

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

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 56-AS-20221128115349

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: CASA MIA	FACILITY NUMBER: 336408502
	VISIT DATE: 12/05/2022

NARRATIVE

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Four (4) of four (4) employees interviewed deny verbally abusing or not treating residents with dignity and respect. It is reported that R1 increasingly demanded staff's attention and would cry and yell if demands were not met immediately by four (4) of four (4) employes interviewed.

We have found the complaint allegation is unsubstantiated, although the allegation may have happened or is valid: there is not a preponderance of the evidence to prove that the alleged violation occurred. A copy of this report is being reviewed with and furnished to the facility representative.

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Amy Goldenberg	TELEPHONE: (951) 201-3990
LICENSING EVALUATOR SIGNATURE:	DATE: 12/05/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2022

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 56-AS-20221128115349

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: CASA MIA	FACILITY NUMBER: 336408502
	VISIT DATE: 12/05/2022

NARRATIVE

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Nine (9) of nine (9) residents interviewed state they receive enough food at each meal and that snacks and drinks are also provided.

In regard to the allegation that staff do not allow resident to have access to the telephone, nine (9) of nine (9) residents interviewed report that they have access to a facility telephone or have their own phone. Four (4) of four (4) employees report that R1 was always on the phone.

We have found the complaint allegations are 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.

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Amy Goldenberg	TELEPHONE: (951) 201-3990
LICENSING EVALUATOR SIGNATURE:	DATE: 12/05/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2022

LIC9099 (FAS) - (06/04)

Page: 4 of 4