336413304-8-12-2021-18-AS-NBRN-C7DPJ6-20211001112102

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 336413304
Report Date: 08/12/2021
Date Signed: 08/12/2021 12:50:38 PM

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
12/02/2020 and conducted by Evaluator Anna Bueno

COMPLAINT CONTROL NUMBER: 18-AS-20201202130150

FACILITY NAME:	EBEN HAVEN		FACILITY NUMBER:	336413304
ADMINISTRATOR:	ELIZABETH ODUNJO		FACILITY TYPE:	740
ADDRESS:	30792 STONE CREEK CT.		TELEPHONE:	(951) 679-7754
CITY:	MENIFEE	STATE: CA	ZIP CODE:	92584
CAPACITY:	6	CENSUS: 5	DATE:	08/12/2021
		UNANNOUNCED	TIME BEGAN:	11:12 AM
MET WITH:	Elizabeth Odunjo		TIME COMPLETED:	01:00 PM

ALLEGATION(S):

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Staff failed to provide proper supervision, which resulted in a fall.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Anna Bueno conducted a subsequent unannounced visit for the purpose of concluding this agency's investigation into the complaint allegation mentioned above. The investigation consisted of file reviews, observations, and staff interview.

The complaint alleges that staff failed to provide supervision that resulted in a fall. Based on interviews and observations, findings for the above allegations is UNSUBSTANTIATED. Resident 1 (R1) slipped when she stood up on her own as Staff 1 (S1) was grabbing toileting supplies. S1 did not leave R1 unsupervised but rather turned her back to grab the supplies, which were in a basket, an arm's away from S1's person. A finding that the complaint is UNSUBSTANTIATED means although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur.

No deficiencies have been cited at this time. An exit interview was conducted where this report was discussed, and a copy was provided to the Ms. Odunjo.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 248-0339
LICENSING EVALUATOR NAME: Anna Bueno	TELEPHONE: 951-204-4307
LICENSING EVALUATOR SIGNATURE:	DATE: 08/12/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2021

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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