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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 336424625
Report Date: 05/15/2025
Date Signed: 05/15/2025 03:15:23 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
04/18/2022 and conducted by Evaluator Debbie Palacios
COMPLAINT CONTROL NUMBER: 18-AS-20220418082844
FACILITY NAME:CHICAGO HOUSE, THEFACILITY NUMBER:
336424625
ADMINISTRATOR:STANGEL, DEBORAHFACILITY TYPE:
735
ADDRESS:15055 CHICAGO AVENUETELEPHONE:
(951) 780-0850
CITY:RIVERSIDESTATE: CAZIP CODE:
92508
CAPACITY:6CENSUS: 5DATE:
05/15/2025
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Victor Hayes, Assistant ManagerTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Lack of supervision resulting in resident leaving the facility.
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Debbie Palacios and Janira Arreola conducted an unannounced visit to the facility to investigate the allegation listed above. LPAs met with Victor Hayes, Assistant Manager and was informed of the purpose of the visit.

During the visit, LPAs toured the facility and conducted two (2) staff interviews, one (1) confidential witness interview and one (1) client interview. LPAs requested client records, and staff roster for review. It was alleged that client #1 (C1) would AWOL from the facility several times and C1 was observed running into oncoming traffic without staff supervision. Information obtained from Individualized Program Plan (IPP) revealed C1 has a history of AWOL. LPA conducted two (2) staff interviews who reported that C1 would AWOL from the facility at night when only one (1) staff was present at the facility. Both staff revealed the protocol was to immediately call 911 if they were unable to shadow C1 when they AWOL. Staff revealed that an additional staff member was added at night after ongoing AWOLs from C1.



Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Debbie Palacios
LICENSING EVALUATOR SIGNATURE:

DATE: 05/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2025
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-20220418082844
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: CHICAGO HOUSE, THE
FACILITY NUMBER: 336424625
VISIT DATE: 05/15/2025
NARRATIVE
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LPA interviewed one (1) confidential witness who reported observing clients outside the facility with two (2) staff providing supervision; they reported no clients have been observed out of the facility without a staff.

LPA reviewed client’s IPP report which states that C1 requires constant supervision in all settings due to C1 displaying behaviors that can be a danger to themselves and to others when at home in the community; C1 typically AWOL’s to test the boundaries of staff.

Therefore, based on record review and interviews, the allegation Lack of supervision resulting in resident leaving the facility, is substantiated.

The preponderance of evidence standard has been met; therefore the above allegation is found to be substantiated. California Code of Regulations Title 22, are being cited on the attached LIC 9099 D. An exit interview was conducted, and a copy of this report was provided.
SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Debbie Palacios
LICENSING EVALUATOR SIGNATURE:

DATE: 05/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 18-AS-20220418082844
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: CHICAGO HOUSE, THE
FACILITY NUMBER: 336424625
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/15/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/15/2025
Section Cited
CCR
80065(a)
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(a) Facility personnel shall be competent to provide the services necessary to meet individual client needs and shall, at all times, be employed in numbers necessary to meet such needs.
This requirement was not met as evidence by:
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The Licensee agree to provide a written plan on addressing C1 AWOL's behavior by the POC due date.
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Based on interview and record review, C1 AWOled from the facility without staff supervision. This poses an immediate health and safety or personal rights risk to clients 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: Rikesha Stamps
LICENSING EVALUATOR NAME: Debbie Palacios
LICENSING EVALUATOR SIGNATURE:

DATE: 05/15/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3