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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 360909246
Report Date: 12/03/2025
Date Signed: 12/03/2025 05:17:36 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO 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
03/26/2024 and conducted by Evaluator Renese Howell-Small
COMPLAINT CONTROL NUMBER: 56-AS-20240326115055

FACILITY NAME:PADUA VILLAGE, INC.FACILITY NUMBER:
360909246
ADMINISTRATOR:SHAWN F. BARRACKSFACILITY TYPE:
735
ADDRESS:11981 MIDWAY RD.TELEPHONE:
(760) 248-6245
CITY:LUCERNE VALLEYSTATE: CAZIP CODE:
92356
CAPACITY:26CENSUS: 24DATE:
12/03/2025
UNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Program Director, Dorris MooreTIME COMPLETED:
05:20 PM
ALLEGATION(S):
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Staff are opening residents mail
Staff made inappropriate comments towards resident
INVESTIGATION FINDINGS:
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On 12/03/2025 Licensing Program Analyst (LPA) Renese Howell-Small conducted an unannounced visit to the facility to deliver findings for the above allegations. LPA discussed the purpose of the visit with Program Director, Dorris Moore.

The allegation that staff are opening residents mail is SUBSTANTIATED.

Interviews with multiple staff revealed that staff opened clients mail without the client's knowledge or presence. Based upon interviews, this allegation is SUBSTANTIATED.

The allegation that staff made inappropriate comments towards resident is SUBSTANTIATED.
Staff stated that Client 1 (C1) would leave the facility often and would return from family visits without having taken their medication. Staff observed other staff address C1 in a argumentative manner. Based on interviews, this allegation is SUBSTANTIATED.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Renese Howell-Small
LICENSING EVALUATOR SIGNATURE:

DATE: 12/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 56-AS-20240326115055
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: PADUA VILLAGE, INC.
FACILITY NUMBER: 360909246
VISIT DATE: 12/03/2025
NARRATIVE
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SUBSTANTIATED is defined as the complaint allegation(s) is valid and a violation has occurred based on the preponderance of available evidence. Deficiencies will be cited.

An exit interview was conducted where this report LIC9099, LIC9099D and Appeal Rights were discussed, and a copies were provided to Shift Lead, Destiny York.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Renese Howell-Small
LICENSING EVALUATOR SIGNATURE:

DATE: 12/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5
Control Number 56-AS-20240326115055
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: PADUA VILLAGE, INC.
FACILITY NUMBER: 360909246
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/03/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/04/2025
Section Cited
CCR
85072(b)(10)
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85072 Personal Rights
(b) The licensee shall insure that each client is accorded the following personal rights. (10) To mail and receive unopened correspondence.
This requirement was not met as evidenced by:
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Administrator will conduct a staff training on personal rights and adhere to the facility policy of opening mail in the presence of the client(s) and or with their written permission. Administrator will submit proof of staff training to LPA by Plan of Correction (POC) due date.
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Based on interview, staff opened Client 1's (C1) mail without their knowledge and not in the presense of client, which posed an immediate risk to the health and safety of client.
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Type A
12/04/2025
Section Cited
CCR
80072(a)(1)
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80072 Personal Rights (a)... each client shall have personal rights which include, but are not limited to, the following:(1) To be accorded dignity in his/her personal relationships with staff and other persons. This requirement not met as evidenced by:
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Administrator will conduct a staff training on challenging behaviors and redirection and submit proof of training to LPA by Plan of Correction (POC) due date.
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Based on interviews, the Administrator did not ensure that staff addressed C1 with dignity and respect, which posed an immediate risk to the health and safety of client 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: Karen Clemons
LICENSING EVALUATOR NAME: Renese Howell-Small
LICENSING EVALUATOR SIGNATURE:

DATE: 12/03/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 5