336426105-9-2-2021-18-AS-NBRN-C6UN8H-20210914101420

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 336426105
Report Date: 09/02/2021
Date Signed: 09/02/2021 03:50:10 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
01/08/2020 and conducted by Evaluator Stephanie Torres

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20200108161459

FACILITY NAME:	MEMBERS CLUB WINCHESTER		FACILITY NUMBER:	336426105
ADMINISTRATOR:	STIEN BAWENGAN		FACILITY TYPE:	735
ADDRESS:	34827 VINEYARD GREEN CT.		TELEPHONE:	(951) 926-7920
CITY:	WINCHESTER	STATE: CA	ZIP CODE:	92596
CAPACITY:	4	CENSUS: 4	DATE:	09/02/2021
		UNANNOUNCED	TIME BEGAN:	01:40 PM
MET WITH:	Stein Bawengan, Administrator		TIME COMPLETED:	02:15 PM

ALLEGATION(S):

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Staff caused injury to client while in care

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA), Stephanie Torres, conducted an unannounced visit at Members Club Winchester to initiate the investigation into the above allegation. The LPA was greeted and granted entrance into the home by Administrator, Stein Bawengan.

Regarding the allegation, "Staff caused injury to client while in care," it was alleged Client One (C1) was observed with a bruise on their right arm and claimed, on December 19, 2019, the bruise was caused by Staff One (S1). A review of the facility staff roster revealed no staff listed by the exact name identified in the allegation. Staff Two (S2) and Three (S3), who share a similar name as S1 were interviewed; each denied the allegation. The Administrator was interviewed; she reported she does not have any information regarding the client being physically assaulted and she did not have any idea where the bruises were coming from. C1 was interviewed, though did not provide a statement. Interviews also reported C1 has been known to identify different staff/clients by name, when questioned about an injury. In addition, a Serious Incident Report (SIR)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Stephanie Torres	TELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:	DATE: 09/02/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/02/2021

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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Control Number 18-AS-20200108161459

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: MEMBERS CLUB WINCHESTER	FACILITY NUMBER: 336426105
	VISIT DATE: 09/02/2021

NARRATIVE

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revealed a bruise was observed on C1's arm, on December 11, 2019, and the client stated "Pinched Asian" when questioned about the injury. Therefore, based on a lack of information, this allegation is deemed UNSUBSTANTIATED at this time. A finding that the complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

This report was reviewed with Bawengan and a copy was provided.

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Stephanie Torres	TELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:	DATE: 09/02/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/02/2021

LIC9099 (FAS) - (06/04)

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