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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 361800461
Report Date: 07/09/2025
Date Signed: 07/09/2025 03:03:51 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
07/03/2025 and conducted by Evaluator Magda Malcore
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20250703155141
FACILITY NAME:SKIOMAH ROADFACILITY NUMBER:
361800461
ADMINISTRATOR:SHARDE CARR, ERICAFACILITY TYPE:
735
ADDRESS:13159 SKIOMAH ROADTELEPHONE:
(818) 309-7821
CITY:APPLE VALLEYSTATE: CAZIP CODE:
92308
CAPACITY:6CENSUS: 4DATE:
07/09/2025
UNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Reba JordanTIME COMPLETED:
03:05 PM
ALLEGATION(S):
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Licensee did not ensure staff were present to receive clients at the facility
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Magda Malcore conducted an unannounced complaint visit to the facility. LPA was granted entry into the facility and met with Administrator, Reba Jordan. The investigation consisted of pertinent document review and interviews with clients, staff and Licensee.

Regarding the allegation, licensee did not ensure staff were present to receive clients at the facility, interviews with the Licensee, two (2) staff, and three (3) clients reveal that recently clients returned from day program via an outside transportation company and staff where not present at the facility to receive clients. The transportation company has arrived at the facility to drop off clients at around 1:45 p.m. However, facility staff do not start their shift until 2:00 p.m. Licensee stated that there is an agreement between the transportation company to drop off clients after 2:00 p.m. However, no documentation was provided to LPA.

Based on investigation findings, the allegation is Substantiated. A finding that the complaint is Substantiated means that the allegation(s) is valid because the preponderance of the evidence standard has been met.


Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Magda Malcore
LICENSING EVALUATOR SIGNATURE:

DATE: 07/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2025
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 3
Control Number 56-AS-20250703155141
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: SKIOMAH ROAD
FACILITY NUMBER: 361800461
VISIT DATE: 07/09/2025
NARRATIVE
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An exit interview was conducted where reports (LIC9099, LIC9099-C, LIC9099-D) were discussed and provided with appeal rights to the Administrator at the conclusion of the visit.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Magda Malcore
LICENSING EVALUATOR SIGNATURE:

DATE: 07/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 56-AS-20250703155141
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: SKIOMAH ROAD
FACILITY NUMBER: 361800461
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/09/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/18/2025
Section Cited
CCR
80065(a)
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80065 Personnel Requirements (a) Facility personnel shall...provide the services necessary to meet individual client needs and shall, at all times, be employed in numbers necessary to meet such needs...this requirement is not met as evidenced by:
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The Licensee stated that the Administrator has been scheduled to work 10am to 2pm to ensure there is staff to meet the clients when returning from program and documentation was provided to LPA.
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The Licensee did not comply with the section cited above by not having staff working/present at the time clients return from program; this 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: 07/09/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3