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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 361880567
Report Date: 11/22/2022
Date Signed: 11/22/2022 09:30:16 AM

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
, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/16/2022 and conducted by Evaluator Melody Brown
COMPLAINT CONTROL NUMBER: 56-AS-20220316163728
FACILITY NAME:YUCCA RESIDENTIALFACILITY NUMBER:
361880567
ADMINISTRATOR:ROJAS, DIANAFACILITY TYPE:
735
ADDRESS:16320 YUCCA AVETELEPHONE:
(760) 843-7676
CITY:VICTORVILLESTATE: CAZIP CODE:
92395
CAPACITY:4CENSUS: 3DATE:
11/22/2022
ANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Licensee/Administrator Diana RojasTIME COMPLETED:
09:45 AM
ALLEGATION(S):
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Staff engaged in physical altercation with a resident while in care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Melody Brown met with Licensee/Administrator Diana Rojas at Community Care Licensing Division (CCLD) Adult and Senior Care (ASC) Regional Office 11/22/2022 at 08:30 AM to deliver findings for the allegation listed above. LPA Brown explained the purpose of the requested Office Visit. The investigation consisted of interviews and review of pertinent documentations.

The allegation indicates that Staff engaged in physical altercation with a resident while in care. LPA Brown did not find evidence to corroborate the allegation. Staffs and Clients were interviewed last 03/23/2022 and denied witnessing the reported physical altercation between a staff and a resident. Staff 1-3 (S1 -S3) denied engaging in a physical altercation with a client and denied witnessing a staff engaging in physical altercation with a client. Interview with S1 revealed that S4 used Crisis Prevention Intervention (CPI) to Client 1 (C1) last 02/28/2022 and 03/02/2022 due to C1’s uncontrolled aggressive behaviors.
*** Continuation on LIC9099 ***
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 11/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2022
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-20220316163728
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
, CA 92507
FACILITY NAME: YUCCA RESIDENTIAL
FACILITY NUMBER: 361880567
VISIT DATE: 11/22/2022
NARRATIVE
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Staff 4 (S4) reported used of CPI to C1 last 02/28/2022 and 03/02/2022 due to C1’s aggressive behaviors that presents an immediate danger to self or to others.

LPA Brown observed Special Incident Reports (SIR) submitted to report the used of CPI to C1. Interviews with Clients indicated they have never seen any staff engaged in physical altercation with a client. Interview with C1 indicated S4 and C1 were involved in physical altercation last 02/28/2022 and 03/02/2022. Per review of C1’s most recent Individual Program Plan (IPP), and interview with Inland Regional Center (IRC) staff indicated that C1 has a history and still currently showing aggressive behaviors and false statements and/or telling stories of things that did not happen.

Based on interviews and observations, and although the above allegations may have occurred or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation staff engaged in physical altercation with a resident is UNSUBSTANTIATED at this time.

An exit interview was conducted where this report (LIC9099) was discussed and provided to Licensee/Administrator Diana Rojas.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 11/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2