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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 361880562
Report Date: 12/13/2023
Date Signed: 12/13/2023 08:32:30 PM

Unsubstantiated


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
11/17/2023 and conducted by Evaluator Paola Guerrero
COMPLAINT CONTROL NUMBER: 56-AS-20231117142707
FACILITY NAME:JEV'S PLACEFACILITY NUMBER:
361880562
ADMINISTRATOR:BERUMEN, MONICA MICHELEFACILITY TYPE:
735
ADDRESS:8345 DURANGO AVETELEPHONE:
(909) 427-0904
CITY:FONTANASTATE: CAZIP CODE:
92335
CAPACITY:4CENSUS: 3DATE:
12/13/2023
UNANNOUNCEDTIME BEGAN:
07:29 PM
MET WITH:Monica BerumenTIME COMPLETED:
08:35 PM
ALLEGATION(S):
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9
Facility staff did not dispense medications as prescribed.
INVESTIGATION FINDINGS:
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13
Licensing Program Analyst (LPA) Paola Guerrero conducted an unannounced visit to deliver findings on the allegation listed above. LPA met with Facility Administrator Monica Berumen and explained the purpose of the visit. The investigation consisted of interviews and a review of records.

First allegation, Facility staff did not dispense medications as prescribed. LPA conducted interviews with Client #1 Client #2 and Client #3 who all stated that facility dispenses medication on time and have no issues with their medication. Client #1 indicated to LPA that client missed medication because client fell asleep and does not like to be bothered or waken up by staff. Based on record review LPA observed that client missed/refused (AM) medications on 11/13/2023. LPA conducted an interview with Facility Administrator who indicated that per regulation medications cannot be dispensed after an hour when medication is due and need the approval from a physician to administer medication.

Based on the evidence obtained during the course of the investigation, LPA has determined that the above allegation is Unsubstantiated.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Paola Guerrero
LICENSING EVALUATOR SIGNATURE:

DATE: 12/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/13/2023
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-20231117142707
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: JEV'S PLACE
FACILITY NUMBER: 361880562
VISIT DATE: 12/13/2023
NARRATIVE
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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 report (LIC 9099) was discussed, and a copy was provided to Facility Administrator Monica Berumen at the end of the visit.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Paola Guerrero
LICENSING EVALUATOR SIGNATURE:

DATE: 12/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/13/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2