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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 361880596
Report Date: 06/29/2023
Date Signed: 06/29/2023 01:14:16 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
04/11/2023 and conducted by Evaluator Rayshaun Nickolas
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20230411093534
FACILITY NAME:CAROLINE STREETFACILITY NUMBER:
361880596
ADMINISTRATOR:PATRICIA WOODSFACILITY TYPE:
735
ADDRESS:14461 CAROLINE STTELEPHONE:
(442) 249-1310
CITY:ADELANTOSTATE: CAZIP CODE:
92301
CAPACITY:4CENSUS: 4DATE:
06/29/2023
UNANNOUNCEDTIME BEGAN:
01:01 PM
MET WITH:Shazet Knowles, caregiverTIME COMPLETED:
01:19 PM
ALLEGATION(S):
1
2
3
4
5
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7
8
9
Staff member is under the influence while at the facility.
Facility does not have sufficient staff.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Rayshaun Nickolas visited the facility unannounced to deliver the finding on the above allegation. LPA met with caregiver Shazet Knowles and explained the purpose of the visit. The investigation included file reviews and interviews with relevant parties.

Allegation #1 “Staff member is under the influence while at the facility”. The allegation alleged that staff #1 (S1) sometimes arrives at work drunk. The allegation alleged that S1 had marijuana on their person at work. LPA Nickolas’ interviews with staff #1 (S1), staff #2 (S2), staff #3 (S3), and staff #4 (S4), revealed that everyone denied this allegation. The finding is Unsubstantiated. There is no evidence or witnesses to corroborate the allegation.

Allegation #2 “Facility does not have sufficient staff”. The allegation alleged that the facility has one (1) person caring for four (4) residents.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Rayshaun Nickolas
LICENSING EVALUATOR SIGNATURE:

DATE: 06/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/29/2023
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-20230411093534
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: 06/29/2023
NARRATIVE
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LPA Nickolas’ interview with S1 revealed that S1 confirmed this allegation. LPA Nickolas’ interview with S2 revealed that S2 denied this allegation. LPA Nickolas’ interview with S3 revealed that S3 confirmed this allegation. S3 stated that at the time of this allegation, the facility had an outbreak, two (2) staff quit, and frequent call-outs by other members of the facility staff. S3 stated that the house manager would send text messages to facility staff members to pick up extra shifts to cover the impacted shifts. LPA Nickolas’ interview with S4 revealed that the outbreak in the facility at the time this allegation was made and staff call-outs made it challenging to ensure that two (2) people were assigned per shift. LPA Nickolas’ review of the staff schedules for April 2, 2023- April 15, 2023, revealed that numerous shifts during that period did not have adequate staffing. During today's visit, LPA Nickolas observed that the facility had adequate staffing. The finding is Unsubstantiated. There is no evidence or witnesses to corroborate the allegation.

A finding of Unsubstantiated means 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 and copy of this report was provided.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Rayshaun Nickolas
LICENSING EVALUATOR SIGNATURE:

DATE: 06/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/29/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2