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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 361880602
Report Date: 10/16/2023
Date Signed: 10/16/2023 01:07:41 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
07/06/2023 and conducted by Evaluator Rayshaun Nickolas
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20230706085846
FACILITY NAME:IRIS STREETFACILITY NUMBER:
361880602
ADMINISTRATOR:PATRICIA ANN WOODSFACILITY TYPE:
735
ADDRESS:14733 IRIS STTELEPHONE:
(442) 249-1457
CITY:ADELANTOSTATE: CAZIP CODE:
92301
CAPACITY:4CENSUS: 3DATE:
10/16/2023
UNANNOUNCEDTIME BEGAN:
12:38 PM
MET WITH:Patricia Woods, AdministratorTIME COMPLETED:
01:12 PM
ALLEGATION(S):
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Facility staff failed to maintain supplies of staple perishable and nonperishable foods at the facility.
Facility staff did not ensure that required bedroom furnitures was provided to clients.
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 administrator Patricia Woods and discussed the purpose of the visit. The investigation included a facility tour, file reviews, and interviews with relevant parties.

Allegation #1 “Facility staff failed to maintain supplies of staple perishable and nonperishable foods at the facility”. The allegation alleged that during construction at the facility, the reporting party (RP) observed the cabinets in the kitchen missing and the refrigerator covered and taped. LPA Nickolas’ interview with staff #1 (S1) revealed that they denied this allegation. LPA Nickolas' interview with staff #2 (S2) revealed that they denied this allegation. LPA Nickolas' interview with resident # 1 (R1) and resident #2 (R2) could not provide information about this allegation. LPA Nickolas' interview with resident # 3 (R3) and resident #4 (R4) could not participate in the interview process. On July 12, 2023, LPA Nickolas' arrived at the facility to conduct an initial complaint investigation visit. During that visit, LPA Nickolas conducted a food audit and determined that the facility had sufficient food to meet all the residents' needs according to regulatory requirements. 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 5
Control Number 56-AS-20230706085846
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: 10/16/2023
NARRATIVE
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Allegation #2 “Facility staffs did not ensure that required bedroom furniture were provided to clients”. The allegation alleged that during construction at the facility, the RP observed missing furniture. The allegation also alleged that the RP observed a resident’s bed uncovered in the center of their room, with only a mattress cover and a blanket. LPA Nickolas’ interview with S1 revealed that could not confirm or deny this allegation. LPA Nickolas’ interview with S2 revealed that S2 denied this allegation. LPA Nickolas' interview with resident R1 and R2 could not provide information about this allegation. LPA Nickolas' interview with R3 and R4 could not participate in the interview process. On July 12, 2023, LPA Nickolas' arrived at the facility to conduct an initial complaint investigation visit. During that visit, LPA Nickolas' tour of the facility revealed no evidence of construction. LPA Nickolas' tour of the facility revealed that all residents' rooms had bedding, furniture, and sufficient lighting as required by regulations. LPA Nickolas also observed that all bedding and furniture in each resident's room was in good repair. 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 a copy of this report was provided.

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 5
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
07/06/2023 and conducted by Evaluator Rayshaun Nickolas
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20230706085846

FACILITY NAME:IRIS STREETFACILITY NUMBER:
361880602
ADMINISTRATOR:PATRICIA ANN WOODSFACILITY TYPE:
735
ADDRESS:14733 IRIS STTELEPHONE:
(442) 249-1457
CITY:ADELANTOSTATE: CAZIP CODE:
92301
CAPACITY:4CENSUS: 3DATE:
10/16/2023
UNANNOUNCEDTIME BEGAN:
12:38 PM
MET WITH:Patricia Woods, AdministratorTIME COMPLETED:
01:12 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility staff failed to notify licensing agency of the construction or renovation at the facility.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
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9
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12
13
Licensing Program Analyst (LPA) Rayshaun Nickolas arrived at the facility unannounced to deliver findings on the above allegation. LPA Nickolas met with administrator Patricia Woods and discussed the purpose of the visit. The investigation included a facility tour, file reviews, and interviews with pertinent parties.

The allegation alleged that the facility staff failed to notify the licensing agency of the construction or renovation at the facility. LPA Nickolas’ interview with the administrator revealed that the administrator confirmed this allegation. LPA Nickolas’s file review revealed that the licensee or facility staff failed to notify Community Care Licensing Division (CCLD) about the construction or revocation at the facility.
Based on the evidence gathered during the investigation, the above allegation is Substantiated. A finding that the complaint is Substantiated means that the allegation(s) is valid because the preponderance of the evidence standard has been met.

Substantiated
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: 3 of 5
Control Number 56-AS-20230706085846
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: 10/16/2023
NARRATIVE
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An exit interview was conduct were a copy of this report (LIC 9099), LIC 9099D, and appeal rights were discussed and provide.
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: 4 of 5
Control Number 56-AS-20230706085846
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/16/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/21/2023
Section Cited
CCR
80086(a)
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Alterations to Existing Building or New Facilities(a)
(a) Prior to construction or alterations, all licensees shall notify the licensing agency of the proposed change.
This requirement was not met, as evidenced by the following:
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The Licensee or licensee delegate shall read the cited section and submit a letter of understanding in writing to the regional office (RO) before the POC due date of 10/21/2023.
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Based on interviews and record reviews, the licensee or licensee delegate did not notify CCLD before starting construction, which posed a potential health, safety, and personal rights violation to persons 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: Karen Clemons
LICENSING EVALUATOR NAME: Rayshaun Nickolas
LICENSING EVALUATOR SIGNATURE:

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

DATE: 10/16/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5