336409394-10-1-2025-18-AS-RORN-DMALNZ-20251009085509

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 336409394
Report Date: 10/01/2025
Date Signed: 10/01/2025 02:31:05 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
04/07/2022 and conducted by Evaluator Antonine Richard

COMPLAINT CONTROL NUMBER: 18-AS-20220407111001

FACILITY NAME:	JONES ADULT CARE FACILITY I		FACILITY NUMBER:	336409394
ADMINISTRATOR:	DEBORAH L. COLLINS		FACILITY TYPE:	735
ADDRESS:	24211 FINLEY AVENUE		TELEPHONE:	(951) 247-1577
CITY:	MORENO VALLEY	STATE: CA	ZIP CODE:	92553
CAPACITY:	6	CENSUS: 2	DATE:	10/01/2025
		UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Sheila Evans		TIME COMPLETED:	02:45 PM

ALLEGATION(S):

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Staff pushed a client while in care.
Staff threatened a client while in care.

INVESTIGATION FINDINGS:

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On 10/01/2025 at approximately 10:00 AM, Licensing Program Analyst (LPA) Antonine Richard conducted a subsequent unannounced complaint visit. LPA met the staff, Sheila Evans. LPA Richard explained the purpose of this visit. later was joined with Administrator Deborah collins. (A1.
The investigation included the following: On October 1, 2025, the Licensing Program Analyst (LPA) conducted interviews with Client #2 (C2) and Staff Member #1 (S1). LPA interviewed Administrator (A1). The LPA also interviewed representatives from the Inland Regional Center (IRC). Additionally, the LPA obtained and reviewed several documents, including the Staff Roster and Resident Roster. A copy of Client #1's (C1) face sheet dated February 17, 2021. Admission Agreement dated April 30, 2021. Physician's Report for Adult Residential. Care (ARC) or LIC 602A dated April 6, 2021. Facility notes from April 4, 2022, to April 18, 2022. Unusual Incident Report (SIR) covering the period from April 4, 2022, to August 9, 2022. It was noted that Client #1 moved out of the facility on August 10, 2022, taking all personal belongings with them.
Evaluation Report continues LIC 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Antonine Richard
LICENSING EVALUATOR NAME: Antonine Richard
LICENSING EVALUATOR SIGNATURE:	DATE: 10/01/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/01/2025

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-20220407111001

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: JONES ADULT CARE FACILITY I	FACILITY NUMBER: 336409394
	VISIT DATE: 10/01/2025

NARRATIVE

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Allegation #1: Staff pushed a client while in care.

The complaint alleged that staff member prevented a client from entering the kitchen by pushing them. On October 1, 2025, at approximately 10:00 AM, LPA Richard interviewed Staff Member 1 (S1), who denied the allegation and stated that they would never push a client, emphasizing that the client has rights and should be treated with respect.

At the same time, LPA interviewed the Administrator (A1), who also denied the allegation, asserting that S1 cares about the clients and would never push or harm them.

At approximately 10:30 AM on the same day, LPA conducted a phone interview with Client 2 (C2), who denied witnessing any incident where a staff member pushed clients. LPA also interviewed the IRC, which claimed not to know any staff member pushing Client 1 (C1).

Additionally, LPA reviewed the facility notes dated April 4, 2022, to April 18, 2022, and the unusual Incident Report (SIR) from April 4, 2022, which indicated that C1 was involved in pushing other clients into care. LPA examined another SIR dated August 7, 2022, which stated that C1 required a higher level of care and received a 3-day notice. On August 10, 2022, C1 was relocated to another home. On October 1, 2025, LPA attempted to interview C1 but was unable to do so as C1 no longer resides at the facility.

Based on interviews, available evidence, observation, information received, and records reviewed, there was not sufficient evidence to support the allegation. 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 deemed unsubstantiated.

SUPERVISORS NAME: Antonine Richard
LICENSING EVALUATOR NAME: Antonine Richard
LICENSING EVALUATOR SIGNATURE:	DATE: 10/01/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/01/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 18-AS-20220407111001

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: JONES ADULT CARE FACILITY I	FACILITY NUMBER: 336409394
	VISIT DATE: 10/01/2025

NARRATIVE

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Allegation: #2: Staff threatened a client while in care.

The complaint alleged that the staff threatened not to transport the client to an appointment. On October 1, 2025, at approximately 10:00 AM, the LPA interviewed Staff Member 1 (S1), who denied the allegation and stated that they would be considered abusive if they threatened clients in any way. The LPA also interviewed the Administrator (A1) on the same day, who likewise denied the allegation and asserted that neither S1 nor other staff members would ever threaten any clients.

At around 10:30 AM on October 1, 2025, LPA conducted a phone interview with Client 2 (C2), who also denied the allegation and stated that staff members had never threatened them or that they had witnessed any staff member threatening other clients. Subsequently, at approximately 10:45 AM, the LPA interviewed the Inland Regional Center (IRC), which claimed not to know of any staff member making threatening remarks.

Records reviewed from the facility indicated that between April 4, 2022, and April 18, 2022, an Unusual Incident Report (SIR) documented that Client 1 (C1) threatened another client in care. Additionally, another SIR dated August 7, 2022, indicated that C1 required a higher level of care and was issued a 3-day notice. C1 was moved to another home on August 10, 2022. On October 1, 2025, The LPA attempted to interview C1 but was unsuccessful, as C1 no longer resided at the facility.

SUPERVISORS NAME: Antonine Richard
LICENSING EVALUATOR NAME: Antonine Richard
LICENSING EVALUATOR SIGNATURE:	DATE: 10/01/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/01/2025

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 18-AS-20220407111001

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: JONES ADULT CARE FACILITY I	FACILITY NUMBER: 336409394
	VISIT DATE: 10/01/2025

NARRATIVE

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No deficiencies cited.

Exit interview conducted. A copy of the report was provided to the staff member Sheila Evans.

SUPERVISORS NAME: Antonine Richard
LICENSING EVALUATOR NAME: Antonine Richard
LICENSING EVALUATOR SIGNATURE:	DATE: 10/01/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/01/2025

LIC9099 (FAS) - (06/04)

Page: 4 of 4