<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 361880596
Report Date: 02/07/2023
Date Signed: 02/07/2023 01:09:42 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
, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/02/2023 and conducted by Evaluator Rayshaun Nickolas
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20230202161101
FACILITY NAME:CAROLINE STREETFACILITY NUMBER:
361880596
ADMINISTRATOR:FACILITY TYPE:
735
ADDRESS:14461 CAROLINE STTELEPHONE:
(442) 249-1310
CITY:ADELANTOSTATE: CAZIP CODE:
92301
CAPACITY:4CENSUS: 4DATE:
02/07/2023
UNANNOUNCEDTIME BEGAN:
09:53 AM
MET WITH:Shazet Knowles, CaregiverTIME COMPLETED:
01:15 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility staff molest client in care
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Rayshaun Nickolas made an unannounced visit to the facility to investigate the above allegation. LPA met with caregiver Shazet Knowles and explained the purpose of the visit. The investigation consisted of file reviews and interviews with relevant parties. LPA also toured the facility inside and out.

The allegation alleges that facility staff molest client in care. Resident #1 (R1) reported to the Reporting Party (RP) that staff # 1 (S1) molested them and their mother. R1 further stated to the RP that their mother is locked in the garage. However, the investigation revealed that R1’s mother resides in a home away from the facility. LPA interview with R1 revealed that R1 does not remember if the allegation happened. LPA interviews with the licensee and facility staff revealed that they reviewed the facility camera footage, and the video footage does not show S1 ever entering R1’s room nor there is no witnesses or evidence that R1 was molested while in care.


Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Rayshaun Nickolas
LICENSING EVALUATOR SIGNATURE:

DATE: 02/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/07/2023
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-20230202161101
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: CAROLINE STREET
FACILITY NUMBER: 361880596
VISIT DATE: 02/07/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Investigation into this incident reveals insufficient evidence and no witnesses to corroborate the allegation.

Based on the investigation, the is findings are Unsubstantiated. A finding of unsubstantiated means although the allegations 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 and copy of this report was provided to Knowles.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Rayshaun Nickolas
LICENSING EVALUATOR SIGNATURE:

DATE: 02/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/07/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2