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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 361880567
Report Date: 03/01/2022
Date Signed: 03/01/2022 02:46:10 PM

Substantiated


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
02/23/2022 and conducted by Evaluator Shaunte Henry
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20220223120135
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: 4DATE:
03/01/2022
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Leo Valle, Lead StaffTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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9
Resident was bit by another resident resulting in an injury
Resident engaged in physical altercation(s) with multiple residents
INVESTIGATION FINDINGS:
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13
On 3/1/22, Licensing Program Analyst (LPA)s Shaunte Henry and Stephanie Williams conducted an unannounced visit for the purpose of investigating the above allegations. The LPA met with lead staff, Leo Valle, explained the nature of the visit and was granted entry.

The investigation, which consisted of file review and interviews revealed the following:
Resident was bit by another resident resulting in injury:
During an interview with Resident 1 (R1), R1 admitted that they bit Resident 2 (R2) and bit Resident 4 (4). The LPAs were not able to interview R2 due to R2 being non-verbal. LPAs were not able to interview R4 because they were at their day program.

***Continued on 9099C***
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Shaunte Henry
LICENSING EVALUATOR SIGNATURE:

DATE: 03/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/01/2022
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 4
Control Number 18-AS-20220223120135
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: YUCCA RESIDENTIAL
FACILITY NUMBER: 361880567
VISIT DATE: 03/01/2022
NARRATIVE
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 ***continued from 9099***

Resident engaged in physical altercations with multiple residents:
During an interview, R1 admitted that they have initiated altercations on several different occasions with R2, R3 and R4. During an interview with Staff 1(S1), S1 confirmed that R1 has had physical altercations with R2, R3 and R4.

Based on LPAs observations and interviews, which were conducted, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6 ) is being cited on the attached LIC9099D. An exit interview was conducted where this report was provided to Leo Valle.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Shaunte Henry
LICENSING EVALUATOR SIGNATURE:

DATE: 03/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/01/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 4
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
02/23/2022 and conducted by Evaluator Shaunte Henry
COMPLAINT CONTROL NUMBER: 18-AS-20220223120135

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: 4DATE:
03/01/2022
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Leo Valle , lead staffTIME COMPLETED:
03:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff engaged in an altercation with resident
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 3/1/22, Licensing Program Analyst (LPA)s Shaunte Henry and Stephanie Williams conducted an unannounced visit for the purpose of investigating the above allegation. The LPA met with lead staff, Leo Valle, explained the nature of the visit and was granted entry. During an interview with Staff 1 (S1), S1 reported that Resident 1 (R1) attacked Staff 2 (S2). S2 ran into a room in an attempt to get away from R1 and R1's arm was accidentally closed in the door. R1 also threw a brick through the window in an attempt to get into the house . R1 also vandalized S1's vehicle. S1 denied that S2 engaged in an altercation with R1. 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, therefore the allegation is unsubstantiated at this time. An exit interview was conducted where this report was provided to Leo Valle.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Shaunte Henry
LICENSING EVALUATOR SIGNATURE:

DATE: 03/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/01/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 18-AS-20220223120135
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: YUCCA RESIDENTIAL
FACILITY NUMBER: 361880567
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/01/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/04/2022
Section Cited
CCR
85065(b)
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7
The licensee shall employ staff as necessary to ensure provision of care and supervision to meet client needs.

This requirement was not met as evidenced by
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7
The facility will review, sign the cited regulation, provide training to staff and submit proof to the department by the POC date.
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Based on interviews, Resident (R1) bit Resident 4 (R4) and caused minor injury.

This is a potential health and safety risk to residents in care.
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Type B
03/04/2022
Section Cited
CCR
85065(f)
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7
The licensee shall ensure that all direct services to clients requiring specialized skills are performed by personnel who are licensed or certified to perform the service. This requirement is not evidenced by:
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7
The facility will review and sign the cited regulation and provide training to staff and provide proof to the department by the POC date.
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Based on interviews, R1 initiated multiple altercations with R2, R3 and R4.

This is a potential health and safety for residents 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: Nedra Brown
LICENSING EVALUATOR NAME: Shaunte Henry
LICENSING EVALUATOR SIGNATURE:

DATE: 03/01/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/01/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 4