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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 361800127
Report Date: 08/24/2021
Date Signed: 08/24/2021 02:56:10 PM

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
RIVERSIDE, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/19/2021 and conducted by Evaluator Stephanie Williams
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20210819115730
FACILITY NAME:SAFE HAVEN HOME IFACILITY NUMBER:
361800127
ADMINISTRATOR:WILSON, PAULAFACILITY TYPE:
735
ADDRESS:15821 MCVAY LANETELEPHONE:
(760) 221-1637
CITY:ADELANTOSTATE: CAZIP CODE:
92301
CAPACITY:4CENSUS: 3DATE:
08/24/2021
UNANNOUNCEDTIME BEGAN:
02:25 PM
MET WITH:Jennifer MoorerTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Licensee is refusing to surrender personal property and valuables to client after client's discharge.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Stephanie Williams made an unannounced visit to the facility in order to initiate a complaint investigation into the above allegation. LPA met with Facility Manager, Jennifer Moorer, and discussed the purpose of the visit. The investigation consisted of records review and interviews with staff and clients.

LPA interviewed Client #1 (C1) who stated that they left the facility voluntarily on 8/1/2021; however, C1 stated that they did not bring their personal items with them. C1 stated that UPS came to the facility on two occasions to pick up C1's items but UPS was unable to transport items due to insufficient packaging and labeling. LPA interviewed Staff #1 (S1) and Staff #2 (S2) who confirmed that C1 left voluntarily but did not bring personal items at the time C1 left. S1 and S2 stated that they have instructed C1 to send labels for C1's boxes so that S1 can print the labels and UPS can pick up the items and send appropriately. S1 and S2 also stated that C1 made arrangements for C1's items to be picked up on 8/21/21; however, the individual did not show up. C1 confirmed that the individual who was arranged to pick up C1's items did not show up to the
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Stephanie Williams
LICENSING EVALUATOR SIGNATURE:

DATE: 08/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2021
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 18-AS-20210819115730
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: SAFE HAVEN HOME I
FACILITY NUMBER: 361800127
VISIT DATE: 08/24/2021
NARRATIVE
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facility on 8/21/21. S1 and S2 denied that facility staff is refusing to surrender C1's personal property; instead, S1 and S2 stated that facility staff have encouraged C1 to pick up their items.

Based on evidence obtained during today’s visit, LPA has determined that the above allegation is UNSUBSTANTIATED; meaning that 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 where this reported was discussed and a copy of this report was provided to the facility manager at the conclusion of the visit.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Stephanie Williams
LICENSING EVALUATOR SIGNATURE:

DATE: 08/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 2