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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 336412341
Report Date: 05/15/2024
Date Signed: 05/15/2024 04:05:09 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
05/08/2024 and conducted by Evaluator Stephanie Martinez
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20240508103803
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:
05/15/2024
UNANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:Breanna Bridges, Facility ManagerTIME COMPLETED:
04:10 PM
ALLEGATION(S):
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Staff threaten client in care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Stephanie Martinez, conducted an unannounced visit to the home to start the investigation into the above allegation. The LPA met with Facility Manager, Breanna Bridges, and informed her of the purpose for her visit.

A report was received by the Department alleging facility staff threaten to use CPI (Crisis Prevention Intervention) on Client One (C1) whenever C1 does not follow instructions or is not cooperative. On this visit the LPA conducted staff and client interviews, reviewed records, and obtained copies of relevant documentation. C1 was interviewed and confirmed staff do threaten them with using CPI practices. C1 reported Staff One (S1) and Staff Two (S2) threatened CPI action on 05/05/2024 when they were attempting to take a shower. C1 reported neither S1 nor S2 acted out on the threat to use CPI practices and C1 was able to take a shower. Three (3) staff members who were present during the alleged incident were interviewed. Each staff member reported the client was notified CPI would be utilized after the client came into possession of scissors. Staff interviews reported C1 would not return the scissors. All interviews with staff and clients
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Stephanie Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 05/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2024
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 4
Control Number 18-AS-20240508103803
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: 05/15/2024
NARRATIVE
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confirmed CPI did not end up being utilized during the incident. Therefore, based on interviews, this allegation is deemed UNSUBSTANTIATED at this time. A finding that the complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

This report was reviewed with Facility Manager Bridges and a copy was provided.
SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Stephanie Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 05/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 4