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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 360909246
Report Date: 08/13/2025
Date Signed: 08/13/2025 03:25:14 PM

Substantiated


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
08/08/2025 and conducted by Evaluator Magda Malcore
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20250808154653
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: 22DATE:
08/13/2025
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Dorris MooreTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Facility staff yell at clients in care
Staff do not keep facility free of insects
Staff do not ensure cleaning supplies are stored inaccessible to clients in care
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Magda Malcore conducted an unannounced visit to the complaint visit to the facility. LPA met with Program Manager, Dorris Moore, and informed the purpose for the visit. The department’s investigation consisted of LPA observations, interviews with staff and clients.

Regarding the allegation, facility staff yell at clients in care, the Department’s investigation reveals enough evidence to corroborate the allegation. Interviews with staff and clients reveal that Staff#1(S1) and Staff#2 (S2) have yelled at clients in care.

Regarding the allegation, staff do not keep facility free of insects, it was alleged that the recreation building and residents bedrooms had roaches. LPA conducted a tour of six (6) residents’ bedrooms and recreation building. LPA observed in the recreation building several dead roaches and insects.
***continued on next page***
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Magda Malcore
LICENSING EVALUATOR SIGNATURE:

DATE: 08/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2025
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 4
Control Number 56-AS-20250808154653
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: PADUA VILLAGE, INC.
FACILITY NUMBER: 360909246
VISIT DATE: 08/13/2025
NARRATIVE
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Interview with the Program Director reveals that the insects could be coming in from the garage door gap in the recreation building. An outside exterminator company has serviced the facility, however the inside of the recreation building was not serviced.

Regarding the allegation, staff do not ensure cleaning supplies are stored inaccessible to clients in care, it was alleged that cleaning supplies were kept unlocked in the recreation building. LPA conducted a tour of the facility and recreation building. LPA observed in the recreation building; a Lysol all-purpose cleaning solution stored in an unlocked cabinet.

Based on the Department’s investigation, the above allegations are Substantiated. A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

An exit interview was conducted where this report was discussed and a copy with appeal rights was provided to Program Manager Moore at the conclusion of the visit.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Magda Malcore
LICENSING EVALUATOR SIGNATURE:

DATE: 08/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 56-AS-20250808154653
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: PADUA VILLAGE, INC.
FACILITY NUMBER: 360909246
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/13/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/22/2025
Section Cited
CCR
80072(a)(1)
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80072(a) Except for children’s residential facilities, 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 is not met as evidenced by:
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The Program Manager has agreed to conduct an inservice training with all staff in regarding client personal rights and submit proof of training by POC due date.
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The Licensee did not comply with the section cited above by Staff #1 (S1) and Staff #2 (S2) yelled at staff in a undignified manner, which poses an immediate health, safety and personal rights risk to persons 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: Magda Malcore
LICENSING EVALUATOR SIGNATURE:

DATE: 08/13/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 56-AS-20250808154653
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: PADUA VILLAGE, INC.
FACILITY NUMBER: 360909246
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/13/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/27/2025
Section Cited
CCR
80087(a)(1)
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80087(a)The facility shall be clean, safe, sanitary and in good repair...for the safety and well-being of clients, employees and visitors. (1)The licensee shall take measures to keep the facility free of flies and other insects...This requirement is not met as evidenced by...
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The Program Manager has agreed to clean and install a door sweep garage door to prevent roaches and other insects from entering recreation building.
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The Licensee did not comply with the section cited above by not keeping recreation building free from insects,which poses a immediate health, safety, and personal rights risk to persons in care.
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Type A
08/14/2025
Section Cited
CCR
80087(g)(1)
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80087(g)Disinfectants,cleaning solutions, poisons...and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients. (1)Storage areas for poisons...and other dangerous weapons shall be locked.This requirement is not met as evidenced by:
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The Program Manager has removed the cleaning solution from the unlocked cabinet.
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The Licensee did not comply with the section cited above by Lysol all purpose cleaner was stored in an unlocked cabinet and accessible to clients; which poses an immediate health, safety and personal rights risk to persons 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: Magda Malcore
LICENSING EVALUATOR SIGNATURE:

DATE: 08/13/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 4