361880602-9-25-2023-56-AS-KCLS-CW4TYD-20230928150834

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 361880602
Report Date: 09/25/2023
Date Signed: 09/25/2023 01:41:50 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
04/13/2023 and conducted by Evaluator Rayshaun Nickolas

PUBLIC

COMPLAINT CONTROL NUMBER: 56-AS-20230413100433

FACILITY NAME:	IRIS STREET		FACILITY NUMBER:	361880602
ADMINISTRATOR:	JASPER WARD		FACILITY TYPE:	735
ADDRESS:	14733 IRIS ST		TELEPHONE:	(442) 249-1457
CITY:	ADELANTO	STATE: CA	ZIP CODE:	92301
CAPACITY:	4	CENSUS: 4	DATE:	09/25/2023
		UNANNOUNCED	TIME BEGAN:	01:28 PM
MET WITH:	Melissa King, Direct Support Professional		TIME COMPLETED:	01:46 PM

ALLEGATION(S):

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Staff yelled at client.
Staff pushed client resulting in a fall.
Staff forcibly pulled client's clothing.
Staff attempted to kick client.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Rayshaun Nickolas arrived at the facility unannounced to deliver findings on the above allegations. LPA Nickolas met with Direct Support Professional (DSP), Melissa King and explained the purpose of the visit. The investigation includes a facility tour, file reviews, and interviews with relevant parties.

Allegation #1 “Staff yelled at client”. The allegation alleged that an unknown facility staff member yelled at resident #1 (R1) to get out of the van. LPA Nickolas' interview with the administrator revealed that they denied this allegation. LPA Nickolas' interview with staff #1 (S1) revealed that they denied this allegation. LPA Nickolas attempted to interview resident #1 (R1) and resident #2 (R2), but R1 and R2 could not participate in the interview process. LPA Nickolas' interview with resident #3 (R3) revealed that R3 could not confirm or deny this allegation. LPA Nickolas' interview with resident #4 (R4) revealed that R4 expressed no concerns about residing at the facility. 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: 09/25/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 56-AS-20230413100433

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: IRIS STREET	FACILITY NUMBER: 361880602
	VISIT DATE: 09/25/2023

NARRATIVE

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Allegation #2 “Staff pushed client resulting in a fall”. The allegation alleged that an unknown facility staff member shoved R1 so hard that they fell. LPA Nickolas' interview with the administrator revealed that they denied this allegation. LPA Nickolas' interview with S1 revealed that they denied this allegation. LPA Nickolas attempted to interview R1 and R2, but R1 and R2 could not participate in the interview process. LPA Nickolas' interview with R3 revealed that R3 could not confirm or deny this allegation. LPA Nickolas' interview with R4 revealed that R4 expressed no concerns about residing at the facility. The finding is Unsubstantiated. There is no evidence or witnesses to corroborate the allegation.

Allegation #3 “Staff forcibly pulled client's clothing”. The allegation alleged that an unknown facility staff member pulled R1’s clothing. LPA Nickolas' interview with the administrator revealed that they denied this allegation. LPA Nickolas' interview with S1 revealed that they denied this allegation. LPA Nickolas attempted to interview R1 and R2, but R1 and R2 could not participate in the interview process. LPA Nickolas' interview with R3 revealed that R3 could not confirm or deny this allegation. LPA Nickolas' interview with R4 revealed that R4 expressed no concerns about residing at the facility. The finding is Unsubstantiated. There is no evidence or witnesses to corroborate the allegation.

Allegation #4 “Staff attempted to kick client”. The allegation alleged that an unknown facility staff member lifted their leg as if they were attempting to kick R1. LPA Nickolas' interview with the administrator revealed that they denied this allegation. LPA Nickolas' interview with S1 revealed that they denied this allegation. LPA Nickolas attempted to interview R1 and R2, but R1 and R2 could not participate in the interview process. LPA Nickolas' interview with R3 revealed that R3 could not confirm or deny this allegation. LPA Nickolas' interview with R4 revealed that R4 expressed no concerns about residing at the facility. 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: 09/25/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2023

LIC9099 (FAS) - (06/04)

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