336412341-5-23-2024-18-AS-JDHS-D5RSDH-20240530134711

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 336412341
Report Date: 05/23/2024
Date Signed: 05/23/2024 02:55:34 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
01/03/2024 and conducted by Evaluator Kathleen Banrasavong

COMPLAINT CONTROL NUMBER: 18-AS-20240103120105

FACILITY NAME:	MAYBERRY HOUSE, THE		FACILITY NUMBER:	336412341
ADMINISTRATOR:	DEBORAH STANGEL		FACILITY TYPE:	735
ADDRESS:	40678 MAYBERRY AVE		TELEPHONE:	(951) 652-3556
CITY:	HEMET	STATE: CA	ZIP CODE:	92544
CAPACITY:	4	CENSUS: 4	DATE:	05/23/2024
		UNANNOUNCED	TIME BEGAN:	02:10 PM
MET WITH:	Administrator, Breanna Bridges		TIME COMPLETED:	03:15 PM

ALLEGATION(S):

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Staff are not offering activities to residents in care.

INVESTIGATION FINDINGS:

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Licensing Program Analyst, (LPA) Kathleen Banrasavong conducted an unannounced visit to deliver findings for a complaint investigation regarding the above allegations. LPA met with Administrator, Breanna Bridges, where LPA explained the purpose of the visit and the elements of the allegations. The investigation consisted of observation, interviews with staff members and residents, and records review.
On 01/03/2024, Community Care Licensing received a complaint alleging that staff are not offering activities to residents in care. It was reported that Resident 1 (R1) was going on AWOL (absent without leave) status due to not being offered activities at the facility. Information obtained from an initial interview, it was reported that the staff does not participate in activities when it is time to do crafts, games, or other activities. It was advised that R1 is left to do activities alone. LPA Banrasavong was not able to conduct a subsequent interview with the R1 to clarify information obtained, due to R1’s refusal to be interviewed again. Information obtained from interview with Administrator, Breanna Bridges revealed there are activities offered to the residents daily.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Kathleen Banrasavong
LICENSING EVALUATOR SIGNATURE:	DATE: 05/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 18-AS-20240103120105

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: 05/23/2024

NARRATIVE

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Administrator provided copies of the monthly activities calendar. Administrator also advised that R1 would have behaviors that would limit their participation in some activities, but alternative activities were offered. LPA conducted additional interviews with residents who stated there are activities offered and they have a choice to do alternative activities if they do not want to participate in the scheduled activity for that day. Information obtained from interviews with residents also advised that staff do participate in activities. Information obtained from interviews with residents and staff members indicated there were no issues with offering activities to keep the residents engaged and learning new skills. LPA reviewed schedules for activities for a variety of months and years. The interviews with residents and staff, along with the review of activities calendar, corroborated that there were activities offered at the facility.

Based on the LPA’s observation, interviews, and record review, the allegation that staff are not offering activities to residents in care, may have happened or is valid, but there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur. Therefore, the allegation is unsubstantiated.

An exit interview was conducted, and a copy of this report, were discussed with and provided to the, Administrator, Breanna Bridges.

SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Kathleen Banrasavong
LICENSING EVALUATOR SIGNATURE:	DATE: 05/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2024

LIC9099 (FAS) - (06/04)

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