361880638-6-30-2022-56-AS-NBRN-CHTM9L-20220831092451

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 361880638
Report Date: 06/30/2022
Date Signed: 06/30/2022 02:04:59 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
06/24/2022 and conducted by Evaluator Rohit Lama

PUBLIC

COMPLAINT CONTROL NUMBER: 56-AS-20220624143301

FACILITY NAME:	PINE RESIDENTIAL CARE		FACILITY NUMBER:	361880638
ADMINISTRATOR:	IGARTA, ALICIA		FACILITY TYPE:	735
ADDRESS:	17269 PINE AVE		TELEPHONE:	(909) 333-1356
CITY:	FONTANA	STATE: CA	ZIP CODE:	92335
CAPACITY:	4	CENSUS: 2	DATE:	06/30/2022
		UNANNOUNCED	TIME BEGAN:	12:00 PM
MET WITH:	Alicia Igarta, Administrator		TIME COMPLETED:	02:15 PM

ALLEGATION(S):

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Facility staff made client leave the facility for 3 days a week at 6 hours per day.
Facility staff is denying client access to internet/wifi.

INVESTIGATION FINDINGS:

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At 12:00 PM on 06/30/2022, Licensing Program Analyst (LPA) Rohit Lama conducted an unannounced visit to initiate a complaint investigation and deliver the findings for the allegation listed above. LPA met with Alicia Igarta, Administrator.

LPA conducted interviews with the Administrator and Resident #1 (R1), and Resdient #2 (R2). Resident #3 (R3) and Resident #4 (R4) were not available for interviews.

The frist allegation above states that a client was being forced to leave the home and was not allowed to return for a predetermined amount of time on various days out of the week. The second allegation states that Staff was denying a client access to internet and/or Wi-Fi. During the interview with the Administrator, the Administrator stated that it was an issue of miscommunication and that the matter had already been...

CONTINUED ON LIC 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Rohit Lama
LICENSING EVALUATOR SIGNATURE:	DATE: 06/30/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/30/2022

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-20220624143301

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: PINE RESIDENTIAL CARE	FACILITY NUMBER: 361880638
	VISIT DATE: 06/30/2022

NARRATIVE

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CONTINUED FROM LIC 9099

...resolved with R2 along with the appropriate individulas at Inland Regional Center (IRC). R1 and R2 also stated, during interviews, that this was not the case. Both R1 and R2 stated that there was no truth to the allegation mentioned above.

Based on the evidence gathered during the investigation, the above allegation is found to be Unsubstantiated. 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, therefore the allegation is Unsubstantiated.
LPA conducted an exit interview where this report was discussed with the Licensee. A copy of this report was provided to the Administrator

SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Rohit Lama
LICENSING EVALUATOR SIGNATURE:	DATE: 06/30/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/30/2022

LIC9099 (FAS) - (06/04)

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