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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 336413183
Report Date: 10/17/2022
Date Signed: 10/17/2022 12:48:54 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
10/10/2022 and conducted by Evaluator Jesse Gardner
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20221010101257
FACILITY NAME:ROXIE'S CARE FACILITYFACILITY NUMBER:
336413183
ADMINISTRATOR:YVONNE HOLCOMBEFACILITY TYPE:
735
ADDRESS:25704 MARGARET AVENUETELEPHONE:
(951) 242-2841
CITY:MORENO VALLEYSTATE: CAZIP CODE:
92551
CAPACITY:6CENSUS: 2DATE:
10/17/2022
UNANNOUNCEDTIME BEGAN:
10:55 AM
MET WITH:Yvonne Holcombe, LicenseeTIME COMPLETED:
12:55 PM
ALLEGATION(S):
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Facility refused to receive client back after hospitalization
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Jesse Gardner conducted an unannounced visit to commence an investigation into the above allegation. LPA identified himself and met with Licensee Yvonne Holcombe. Holcombe discussed the purpose of the visit, and toured the facility.

LPA conducted an interview with the Licensee and requested copies of pertinent documents. Regarding the allegation, "Facility refused to receive client back after hospitalization", Interview revealed that Licensee did not return to pick up Client One (C1) on 10/8/22, after being admitted to the hospital. Deficiency cited per Title 22 Division 6.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Deborah Mullen
LICENSING EVALUATOR NAME: Jesse Gardner
LICENSING EVALUATOR SIGNATURE:

DATE: 10/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2022
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 3
Control Number 18-AS-20221010101257
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: ROXIE'S CARE FACILITY
FACILITY NUMBER: 336413183
VISIT DATE: 10/17/2022
NARRATIVE
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Due to C1 not returning to the facility, the allegation was 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 with the Licensee and a copy of this report was discussed with and provided along with a copy of the LIC9099-C, LIC9099-D, and Appeal Rights.
SUPERVISORS NAME: Deborah Mullen
LICENSING EVALUATOR NAME: Jesse Gardner
LICENSING EVALUATOR SIGNATURE:

DATE: 10/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 18-AS-20221010101257
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: ROXIE'S CARE FACILITY
FACILITY NUMBER: 336413183
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/17/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/29/2022
Section Cited
CCR
80072(a)(3)
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Personal Rights
(a) Except..each client shall have personal rights.. (3) To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse, or other actions of a punitive nature, including but not limited to: interference with the daily living functions, including eating, sleeping, or toileting; or withholding of shelter.. This requirement was not being met as evidenced by:
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Licensee states that they will develop a written plan on how they will handle behaviors outside of their controlfrom clients and submit to LPA along with in-service training of the regulation by POC date.
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Based on interview with Licensee, Licensee admitted that C1 was not given shelter as per the regulation. This presents an immediate personal rights risk to residents 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: Deborah Mullen
LICENSING EVALUATOR NAME: Jesse Gardner
LICENSING EVALUATOR SIGNATURE:

DATE: 10/17/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3