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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 336412341
Report Date: 07/13/2023
Date Signed: 07/13/2023 03:11:35 PM

Substantiated


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
RIVERSIDE, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/09/2023 and conducted by Evaluator Javina George
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20230509084136
FACILITY NAME:MAYBERRY HOUSE, THEFACILITY NUMBER:
336412341
ADMINISTRATOR:DEBORAH STANGELFACILITY TYPE:
735
ADDRESS:40678 MAYBERRY AVETELEPHONE:
(951) 652-3556
CITY:HEMETSTATE: CAZIP CODE:
92544
CAPACITY:4CENSUS: 4DATE:
07/13/2023
UNANNOUNCEDTIME BEGAN:
12:47 PM
MET WITH:Brenda Torres, Assistant Facility AdministratorTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Clients in care are not provided adequate food service
Facility has insufficient amounts of foods for clients in care
Facility staff treat some clients differently than others
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Javina George made an unannounced visit to the faciity to deliver findings for the alleagation(s) listed above. LPA met with assistant facility manager Brenda Torres and explained the purpose of her visit and the elements of the allegation(s). The allegations were investigated, the investigation consisted of observations, interviews and record review.

Regarding the allegation of Clients in care are not provided adequate food service
Interviews conducted with multiple clients revealed that the clients are being served 3 meals and two snacks a day. However, the information provided revealed that the clients are not allowed to have seconds and are told they cannot have a second helping because they need to lose weight. LPA asked the clients if their doctor had placed them on a modified diet and the answer was “no”. During the initial complaint visit LPA conducted 0n 5/10/23, a review of all of the client’s facility files revealed they were not observed to be on a modified diet. In addition, LPA was also asked by a client if they would get into trouble if they asked for seconds. Based on interviews and record review the allegation is SUBSTANTIATED.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Javina George
LICENSING EVALUATOR SIGNATURE:

DATE: 07/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/13/2023
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 6
Control Number 18-AS-20230509084136
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
RIVERSIDE, CA 92507
FACILITY NAME: MAYBERRY HOUSE, THE
FACILITY NUMBER: 336412341
VISIT DATE: 07/13/2023
NARRATIVE
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Facility has insufficient amounts of foods for clients in care

Per the facility manager Ms. Hervey, the facility completes their grocery shopping on either Monday or Tuesday each week. The grocery shopping is completed by the facility manager and another designated staff for the day. LPA conducted the initial complaint visit on 5/10/23 and observed for the facility to have the required and sufficient food supply of 2-day perishable and a 7-day supply of nonperishable food items. The facility has a refrigerator located inside of the kitchen, and a refrigerator as well as a deep freezer located outside in the garage. In addition, the facility has an excess of canned fruits, veggies, beans and lentils. Per interviews conducted with staff there is a sufficient amount of food, however due to the facility meal break expectation policy staff are required to eat their meals with the clients. The clients are not served a second helping as there would not be enough for staff to eat. Further, interviews conducted revealed that there are times when items that were purchased from the grocery store have come up missing such as bread and meat (carne asada) with no explanation as to where the items went. In addition, LPA, observed that there was a purchase on 5/9/23, for $20.00 worth of eggs from a local egg farm, however during LPAs visit, LPA observed for the facility to have one (1) carton of eggs. It was confirmed by staff that a purchase for that amount would supply a total 60 eggs. Further staff interviews revealed that there are frequent menu changes as the items or ingredients needed to prepare a meal are not present at the facility, when they initially were. Further interviews revealed that there are not being any additional purchases being made, just constant substitutions for all meals (breakfast, lunch and or dinner. The evidence suggest that the facility does not have insufficient food supply because the items are being taken. Per interviews conducted revealed that staff have observed food either come up missing or have physically witnessed food being taken. The food that is discarded because it has expired is not included. In addition, staff interviews revealed that Staff #1 would make statements such as don’t touch that, that is mine” referring to chips, tortillas and canned goods. Based on observation, interview and record review the allegation of facility has insufficient amounts of food for clients in care is SUBSTANTIATED.

Facility staff treat some clients differently than others

It was reported that there is one client, client #1 (C1) in particular that is treated differently than others by Staff #1 (S1) and staff #2 (S2). Interviews conducted with clients revealed that they have observed (C1) being treated differently. The different treatment presents in the form of C1 getting yelled at and told that they are not allowed to participate in certain activities. An interview with C1 revealed that they felt like they are not wanted there at the facility. Interviews with staff revealed that C1 is treated differently because they want to wear makeup, and, make sure their hair is done a certain way, but they are told “no”. Further

SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Javina George
LICENSING EVALUATOR SIGNATURE:

DATE: 07/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/13/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 18-AS-20230509084136
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
RIVERSIDE, CA 92507
FACILITY NAME: MAYBERRY HOUSE, THE
FACILITY NUMBER: 336412341
VISIT DATE: 07/13/2023
NARRATIVE
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information revealed that C1 will try to address a concern and they are ignored or yelled at to go and do their chores. Staff expressed that there is favoritism amongst the other clients. LPA conducted interviews with both S1 and S2, who denied treating C1 differently. S2 did state that they do in a way treat C1 differently because C1 makes false statements, that anytime they have interaction with C1 they will ensure that there is a witness present. LPA did express that there is nothing wrong with that and would not be considered as different treatment as it pertains to the complaint. Based on interviews the allegation is SUBSTANTIATED. A substantiated finding means that the preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED..

An exit interview was conducted and a copy of this report, 9099D and appeal rights were provided to Brenda Torres, assistant facility manager.

SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Javina George
LICENSING EVALUATOR SIGNATURE:

DATE: 07/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/13/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 6
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
RIVERSIDE, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/09/2023 and conducted by Evaluator Javina George
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20230509084136

FACILITY NAME:MAYBERRY HOUSE, THEFACILITY NUMBER:
336412341
ADMINISTRATOR:DEBORAH STANGELFACILITY TYPE:
735
ADDRESS:40678 MAYBERRY AVETELEPHONE:
(951) 652-3556
CITY:HEMETSTATE: CAZIP CODE:
92544
CAPACITY:4CENSUS: 4DATE:
07/13/2023
UNANNOUNCEDTIME BEGAN:
12:47 PM
MET WITH:Brenda Torres, Assistant Facility ManagerTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Staff mismanaged client funds
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Javina George made an unannounced visit to the faciity to deliver findins for the alleagation listed above. LPA met with assistant facility manager Brenda Torres and explained the purpose of her visit and the elements of the allegation. The allegations were investigated, the investigation consisted of observations, interviews and record review.

Regarding the allegation of staff mismanaged client funds.
It was reported that the clients P&I money was short and missing. There are only two staff (the facility manager and assistant facility manager) that have access to the clients P&I money which is stored inside a locked safe inside the . LPA conducted the initial complaint visit on 5/10/23 and a reviewed all of the clients P&I, all the funds/amount noted on the cash resources log was present and accounted for. An additional visit was conducted on 7/13/23 and an additional review of the clients P&I was conducted and revealed that all P& I was present. It was alleged that the P &I was short and staff was overheard being told that they had
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Javina George
LICENSING EVALUATOR SIGNATURE:

DATE: 07/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/13/2023
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 6
Control Number 18-AS-20230509084136
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
RIVERSIDE, CA 92507
FACILITY NAME: MAYBERRY HOUSE, THE
FACILITY NUMBER: 336412341
VISIT DATE: 07/13/2023
NARRATIVE
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to put the money back when they got paid. There was no evidence to support this as both the facility manager and assistant facility manager denied having this conversation. Based on record review the allegation is UNSUBSTANTIATED. A finding of UNSUBSTANTIATED means 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 and a copy of this report was provided to Brenda Torres, Assistant Facility Administrator.

SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Javina George
LICENSING EVALUATOR SIGNATURE:

DATE: 07/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/13/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 18-AS-20230509084136
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
RIVERSIDE, CA 92507

FACILITY NAME: MAYBERRY HOUSE, THE
FACILITY NUMBER: 336412341
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/13/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type B
07/27/2023
Section Cited
CCR
80072(A)(3)
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Personal rights (a) Except for children’s residential facilities, each client shall have personal rights which include, but are not limited to, the following: (3) To be free from... other actions of a punitive nature, including..: interference with the daily living functions, including eating...
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The licensee agrees to conduct an inservice on clients and their personal rights. Proof of POC is to be submitted to the department by 5om in thendue date indicated.
Deficiency Dismissed
Type B
07/27/2023
Section Cited
CCR
80072(A)(2)
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This requirement is not met as evidenced by: the licensee failed to ensure the clients were afforded the oppotunity to have a second helping of their meal. This poses a potential personal rights risk to persons in care.
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This requirement is not met as evidenced by: the licensee failed to ensure the clients were afforded the oppotunity to have a second helping of their meal. This poses a potential personal rights risk to persons in care.
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80072 (A): each client shall have personal rights which include, but are not limited to, the followingPersonal Rights 80072 A(2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs.
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The Licensee agrees to The licensee agrees to conduct an inservice on clients and their personal rights. Proof of POC is to be submitted to the department by 5om in thendue date indicated.
Request Denied
Type B
07/27/2023
Section Cited
CCR
80072(A)(1)
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80072 Personal Rights (a) Except for... each client shall have personal rights which include(1)To be accorded dignity in his/her personal relationships with staff and other persons. This was not met as the licensee did not ensure C1 was treated with dignity and respect
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This poses a potential personal rights risk to persons in careThe Licensee agrees to The licensee agrees to conduct an inservice on clients and their personal rights. Proof of POC is to be submitted to the department by 5om in thendue date indicated.
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: Joel Esquivel
LICENSING EVALUATOR NAME: Javina George
LICENSING EVALUATOR SIGNATURE:

DATE: 07/13/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/13/2023
LIC9099 (FAS) - (06/04)
Page: 6 of 6