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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 360909246
Report Date: 01/13/2023
Date Signed: 01/13/2023 11:32:55 AM

Unsubstantiated


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
, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/16/2022 and conducted by Evaluator Rayshaun Nickolas
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20220916133953
FACILITY NAME:PADUA VILLAGE, INC.FACILITY NUMBER:
360909246
ADMINISTRATOR:KIMBERLY ROWEFACILITY TYPE:
735
ADDRESS:11981 MIDWAY RD.TELEPHONE:
(760) 248-6245
CITY:LUCERNE VALLEYSTATE: CAZIP CODE:
92356
CAPACITY:26CENSUS: DATE:
01/13/2023
UNANNOUNCEDTIME BEGAN:
09:39 AM
MET WITH:Shawn Barracks, AdministratorTIME COMPLETED:
10:10 AM
ALLEGATION(S):
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Staff inappropriately touched a client while in care
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Rayshaun Nickolas made an unannounced visit to the facility to deliver the finding on the above allegation. LPA met with Administrator Shawn Barracks and explained the purpose of the visit.

On September 19, 2022, LPA Rohit Lama initiated the ten-day complaint investigation into the alleged allegation that "Staff inappropriately touched a client while in care". During the initial ten-day complaint investigation, copies of pertinent documents were requested and collected.

This complaint was investigated by department staff. The investigation consisted of file reviews and interviews with relevant parties. The allegation alleges that sometime at night on September 14, 2022, staff # 1 (S1) entered resident #1 (R1) room and inappropriately touched them. Department staff interviewed S1, who stated that they were assigned to two (2) residents that day (R1) and resident # 2 (R2) because the facility was short-staffed that day.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Rayshaun Nickolas
LICENSING EVALUATOR SIGNATURE:

DATE: 01/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/13/2023
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-20220916133953
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
, CA 92507
FACILITY NAME: PADUA VILLAGE, INC.
FACILITY NUMBER: 360909246
VISIT DATE: 01/13/2023
NARRATIVE
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S1 also stated they were never alone with R1 during their shift and always with R1 and R2 during their shift. S1 denied inappropriately touching R1 or any other resident. Department staff interview with R1 did not reveal that S1 inappropriately touched them. Department staff interview with R2 revealed that they have never felt uncomfortable with any staff at the facility. R2 further recalled being supervised by S1 and acknowledged that S1 also supervised R1. R2 did not report any inappropriate sexual behavior by S1 or anyone else. The finding is Unsubstantiated. There is no evidence or witnesses to corroborate the allegation.

A finding of Unsubstantiated means although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur.

An exit interview was conducted and copy of this report was emailed.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Rayshaun Nickolas
LICENSING EVALUATOR SIGNATURE:

DATE: 01/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/13/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2