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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 361880596
Report Date: 10/16/2023
Date Signed: 10/16/2023 12:15:56 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
10/09/2023 and conducted by Evaluator Rayshaun Nickolas
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20231009161458
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: 3DATE:
10/16/2023
ANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Shazet Knowles, house managerTIME COMPLETED:
12:15 PM
ALLEGATION(S):
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Staff do not provide adequate supervision, resulting in a resident wandering away from the facility.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Rayshaun Nickolas visited the facility unannounced to initiate an investigation and deliver the finding on the above allegation. LPA met with caregiver Kandy Gastelum and explained the purpose of the visit. House manager Shazet Knowles later arrived at the facility. The investigation included a facility tour, file reviews, and interviews with relevant parties.

The allegation alleged that on October 6, 2023, A neighbor pulled into their driveway, parked their car, and resident #1 (R1) opened the neighbor's car door, got inside, and attacked the neighbor. LPA Nickolas' interview with staff #1 (S1) revealed that they confirmed this allegation. LPA Nickolas' interview with staff #2 (S2) confirmed this allegation. LPA Nickolas could not interview R1 because R1 could not participate in the interview process. The investigation into the incident revealed that the facility had sufficient staff to meet R1's needs. The investigation into this incident also revealed that R1 did not wander away due to a lack of supervision. The finding is Unsubstantiated. There is no evidence or witnesses to corroborate the allegation.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Rayshaun Nickolas
LICENSING EVALUATOR SIGNATURE:

DATE: 10/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/16/2023
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-20231009161458
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: 10/16/2023
NARRATIVE
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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.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Rayshaun Nickolas
LICENSING EVALUATOR SIGNATURE:

DATE: 10/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/16/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2