<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 336412341
Report Date: 01/03/2024
Date Signed: 01/03/2024 12:00:44 PM

Substantiated


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
09/20/2021 and conducted by Evaluator Jesse Gardner
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20210920144056
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: 1DATE:
01/03/2024
UNANNOUNCEDTIME BEGAN:
10:52 AM
MET WITH:Elizabeth Evans, CaregiverTIME COMPLETED:
12:07 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff not following residents prescribed diet
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Jesse Gardner conducted an unannounced subsequent complaint visit to the facility. LPA met with Caregiver Elizabeth Evans and informed them of the purpose of this visit. During this investigation, LPA conducted interviews with staff and clients; obtained supportive documentation for review to assist with determining the findings for the above noted allegation. The following was determined.

Allegation #1, Staff were allegedly not following Client #2 (C2’s) prescribed diet. LPA reviewed facility documentation, and interviewed staff. A review of C2’s Physician’s Report indicated that C2 requires a modified diet. Upon review of the menu provided to the clients, staff interviews indicated that C2 is provided with alternate selections.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Jesse Gardner
LICENSING EVALUATOR SIGNATURE:

DATE: 01/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/03/2024
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
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
09/20/2021 and conducted by Evaluator Jesse Gardner
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20210920144056

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: 1DATE:
01/03/2024
UNANNOUNCEDTIME BEGAN:
10:52 AM
MET WITH:Elizabeth Evans, CaregiverTIME COMPLETED:
12:07 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff falsified resident information
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Jesse Gardner conducted an unannounced subsequent complaint visit to the facility. LPA met with Caregiver Elizabeth Evans and informed them of the purpose of this visit. During this investigation, LPA conducted interviews with staff and clients; obtained supportive documentation for review to assist with determining the findings for the above noted allegation. The following was determined.

Allegation #1 – Staff falsified resident information. Concerns that were reported stated that during a doctor visit, staff falsely claimed Client One (C1) needed medication, when they did not. It was alleged that the house manager told the physician this so that they would prescribe C1 a sleeping medication because the night staff have a rough
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Jesse Gardner
LICENSING EVALUATOR SIGNATURE:

DATE: 01/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/03/2024
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 5
Control Number 18-AS-20210920144056
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: MAYBERRY HOUSE, THE
FACILITY NUMBER: 336412341
VISIT DATE: 01/03/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
time putting C1 to bed. It was further alleged that during the appointment, C1's physician prescribed C1 a new medication; however, now C1 allegedly stumbles when walking, falls, and can't get-up out of a chair.

The Department’s investigation consisted of staff interviews, as well as a record review. C1’s placement appraisal dated 05/07/2021 revealed that C1 has motor impairment and an unstable gait. LPA conducted document review and found that C1’s Consumer staff notes indicated that C1’s behavior began on 8/31/2021, when C1 was awake sitting on their bed when NOC shift arrived at approximately 9:00pm. On 09/04/2021, C1 was again found to be up at 3:30am, walking around the facility. On that date, staff were able to redirect C1 back to bed and finally to sleep at 4:00am. On 09/05/2021, C1 was noted to again be awake at 3:10am sitting on their bed, and then displaying behaviors. On 09/07/2021 at about 2:40am, C1 was up and walking around the facility.

C1’s physician prescribed a new medication for C1 to begin on 9/10/21. The medication was to assist with sleeping. C1 did not have any further sleep disturbances after 09/10/2021. Additionally, through staff interviews, and record review, LPA determined that C1 was diagnosed with a medical condition that made them have an unsteady gait, awake episodes at night, and was prescribed sleep medication by C1’s doctor. The Department could not corroborate the allegation, and therefore, was deemed Unsubstantiated as a result.

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 where a copy of this report was discussed with and provided along with copies of the LIC811 (Confidential names list).
SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Jesse Gardner
LICENSING EVALUATOR SIGNATURE:

DATE: 01/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/03/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 18-AS-20210920144056
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: MAYBERRY HOUSE, THE
FACILITY NUMBER: 336412341
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/03/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type B
01/10/2024
Section Cited
CCR
80072(a)(2)
1
2
3
4
5
6
7
80072 Personal Rights: (a) Except for children’s residential facilities, each client shall have personal rights which include, but are not limited to, the following:(2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs. This requirement was not being met as evidenced by:
1
2
3
4
5
6
7
Licensee agrees to conduct in-service training to all staff on the cited regulation, and submit the POC by 5pm on 1/10/2024.
8
9
10
11
12
13
14
Licensee did not provide alternative choices of food to C2. This poses a potential personal rights risk to clients in care.
8
9
10
11
12
13
14
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: Rikesha Stamps
LICENSING EVALUATOR NAME: Jesse Gardner
LICENSING EVALUATOR SIGNATURE:

DATE: 01/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/03/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 18-AS-20210920144056
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: MAYBERRY HOUSE, THE
FACILITY NUMBER: 336412341
VISIT DATE: 01/03/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
However, interview with C2 and other relevant sources, LPA found that alternative selections are not provided to C2, and C2 often chooses not to eat, due to alternatives not being available. Thus, through interviews and review of evidence, this allegation was deemed to be Substantiated.

A finding that the complaint is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met.

An exit interview was conducted where a copy of this report was discussed with and provided along with copies of the LIC811 (Confidential names list), LIC9099C, LIC9099D, and Appeal Rights.
SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Jesse Gardner
LICENSING EVALUATOR SIGNATURE:

DATE: 01/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/03/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5