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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 336412332
Report Date: 04/21/2023
Date Signed: 04/21/2023 11:28:04 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/11/2020 and conducted by Evaluator Paola Guerrero
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20200911104809
FACILITY NAME:NATHANS ADULT RESIDENTIAL CARE HOMEFACILITY NUMBER:
336412332
ADMINISTRATOR:RENANTE BUTELFACILITY TYPE:
735
ADDRESS:10980 KAYJAY ST.TELEPHONE:
(951) 353-2199
CITY:RIVERSIDESTATE: CAZIP CODE:
92503
CAPACITY:6CENSUS: 4DATE:
04/21/2023
UNANNOUNCEDTIME BEGAN:
09:05 AM
MET WITH:Lora Mae Aquino TIME COMPLETED:
11:25 AM
ALLEGATION(S):
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Facility served a 30-day eviction notice without notifying the client's authorized representative
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Paola Guerrero conducted an unannounced visit to deliver findings on the allegation listed above. LPA met with Facility Administrator Lora Mae Aquino and explained the purpose of the visit. The investigation consisted of interviews and review of records.

First Allegation: Facility served a 30-day eviction notice without notifying the client's authorized representative.

Regarding first allegation Facility served a 30-day eviction notice without notifying the client's authorized representative, LPA Guerrero reviewed the documentation provided of the eviction notice that was served to Resident #1 (R1). Based on information provided from Inland Regional Center (IRC), Inland Regional received the 30-day notification pertaining to Resident #1 (R1), Inland Regional Center indicated that it was communicated to the facility that the facility was to notify Resident #1 (R1) conservator. Facility administrator stated that a 30-day eviction notice was issued however, facility failed to notify Resident #1
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Paola Guerrero
LICENSING EVALUATOR SIGNATURE:

DATE: 04/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2023
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
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/11/2020 and conducted by Evaluator Paola Guerrero
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20200911104809

FACILITY NAME:NATHANS ADULT RESIDENTIAL CARE HOMEFACILITY NUMBER:
336412332
ADMINISTRATOR:RENANTE BUTELFACILITY TYPE:
735
ADDRESS:10980 KAYJAY ST.TELEPHONE:
(951) 353-2199
CITY:RIVERSIDESTATE: CAZIP CODE:
92503
CAPACITY:6CENSUS: 4DATE:
04/21/2023
UNANNOUNCEDTIME BEGAN:
09:05 AM
MET WITH:Lora Mae Aquino TIME COMPLETED:
11:25 AM
ALLEGATION(S):
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9
Administrator is not at the facility for a sufficient number of hours
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Paola Guerrero conducted an unannounced visit to deliver findings on the allegation listed above. LPA met with Facility Administrator Lora Mae Aquino and explained the purpose of the visit. The investigation consisted of interviews and review of records.

First Allegation: Administrator is not at the facility for a sufficient number of hours.

Regarding the first allegation of Administrator is not at the facility for a sufficient number of hours.

Through personel report of record review it revealed that the past Administrator worked (M-F hours specified 9am-1pm) hours varied. In addtion, report stated Administrator was on call as needed. Currently the facility has a new Facility Administrator who shares same working shedule as the past Administrator. Shedule in which was provided by the new Facility Administrator. There was not enough evidence to corroborate the allegation. Based on the evidence obtained during the course of the investigation, LPA has determined that the above allegation is UNSUBSTANTIATED.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Paola Guerrero
LICENSING EVALUATOR SIGNATURE:

DATE: 04/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 18-AS-20200911104809
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA
FACILITY NAME: NATHANS ADULT RESIDENTIAL CARE HOME
FACILITY NUMBER: 336412332
VISIT DATE: 04/21/2023
NARRATIVE
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Unsubstantiated: meaning that 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.

An exit interview was conducted where this report (LIC 9099) was discussed, and a copy was provided to the administrator at the end of the visit.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Paola Guerrero
LICENSING EVALUATOR SIGNATURE:

DATE: 04/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5
Control Number 18-AS-20200911104809
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA
FACILITY NAME: NATHANS ADULT RESIDENTIAL CARE HOME
FACILITY NUMBER: 336412332
VISIT DATE: 04/21/2023
NARRATIVE
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(R1) conservator of the eviction. LPA reviewed the contents of the eviction letter and found that the reasoning for the eviction was not valid according to Title 22 Division 6 Chapter 6 Article 6 Subsection 85068.5 (d) eviction procedures. That the licensee shall, upon completion of the procedures, notify or mail a copy of the notice to quit to the client's authorized representative if any. Based on the evidence obtained during the course of the investigation, LPA has determined that the above allegation is Substantiated.

Substantiated. A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Title 22 regulations 85068.5 (d), from division 6, chapter, article 6, is being cited on the attached LIC 9099 D.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Paola Guerrero
LICENSING EVALUATOR SIGNATURE:

DATE: 04/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 18-AS-20200911104809
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA

FACILITY NAME: NATHANS ADULT RESIDENTIAL CARE HOME
FACILITY NUMBER: 336412332
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/21/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/24/2023
Section Cited
CCR
85068.5(d)
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Eviction Procedures (d) The licensee shall, upon completion of the procedures specified in (a) or (b) above, notify or mail a copy of the notice to quit to the client's authorized representative if any.

This requirement is not met as evidence by:
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Licensee is to review section cited and submit a statement of understanding Via email to LPA by POC date of 4/24/23
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Based on interviews and record review, the licensee did not ensure eviction procedures to be correctly followed.Which poses an immediate Health, Safety, or Personal Rights risk to persons 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: Efren Malagon
LICENSING EVALUATOR NAME: Paola Guerrero
LICENSING EVALUATOR SIGNATURE:

DATE: 04/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 5