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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 336425056
Report Date: 10/11/2023
Date Signed: 10/11/2023 02:51:25 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 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
10/04/2023 and conducted by Evaluator Mary Rico
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20231004084031
FACILITY NAME:MANITOBA RESIDENTIAL CAREFACILITY NUMBER:
336425056
ADMINISTRATOR:CHARISSE MCCOYFACILITY TYPE:
735
ADDRESS:1703 MANITOBA CIRCLETELEPHONE:
(951) 531-8952
CITY:CORONASTATE: CAZIP CODE:
92882
CAPACITY:5CENSUS: 3DATE:
10/11/2023
UNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:William Mccoy TIME COMPLETED:
03:10 PM
ALLEGATION(S):
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Staff handled resident in a rough manner
Staff restrained resident
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Mary Rico conducted an unannounced visit to deliver findings on the allegations listed above. LPA met with William Mccoy and explained the purpose of the visit. The investigation consisted of staff interviews, clients interviews, document reviews, and facility tour.

For allegation, Staff handled resident in a rough manner.

During interview with clients, clients stated they have not been handled in a rough manner. C1 denied being handled in rough manner by staff. C2 informed LPA they had no concerns to addressed and love the facility.

During interviews with staff, staff stated they have not handled a resident in a rough manner. S1 informed LPA clients are redirected when a behavior occurs and update client’s IPP for any changes.


Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Mary Rico
LICENSING EVALUATOR SIGNATURE:

DATE: 10/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2023
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 2
Control Number 56-AS-20231004084031
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: MANITOBA RESIDENTIAL CARE
FACILITY NUMBER: 336425056
VISIT DATE: 10/11/2023
NARRATIVE
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For allegation, Staff restrained resident.

During interviews with staff, staff informed LPA they do not restrained clients. As pervious stated staff redirect clients when behaviors occur. S1 informed LPA that C1 has an increase of behaviors. S1 is working on receiving one on one supervision for C1. S1 also, stated their staff have not restrained a client.

During interview with clients, clients stated staff do not restrained them. C1 denied being restrained from facility staff. In addition, C1 stated they throw items to staff when they are upset but have not been restrained from staff.

During facility tour, LPA did not witness any items that may be used as a restrained.

Based on the evidence found during the investigation, the two (2) allegations listed above are deemed UNSUBSTANTIATED. A finding that the complaints are UNSUBSTANTIATED means although the allegation may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur.



During today’s visit, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations.

An exit interview was conducted, and this report was discussed and provided to William Mccoy, along with a copy of the appeal rights.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Mary Rico
LICENSING EVALUATOR SIGNATURE:

DATE: 10/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2