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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 361880720
Report Date: 10/17/2022
Date Signed: 10/17/2022 02:36:08 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/11/2022 and conducted by Evaluator Natalie Ibarra
COMPLAINT CONTROL NUMBER: 56-AS-20221011124034
FACILITY NAME:SHAMROCK CARE HOMEFACILITY NUMBER:
361880720
ADMINISTRATOR:ROMEL C CAPALARANFACILITY TYPE:
735
ADDRESS:1741 ERIN AVETELEPHONE:
(909) 697-9843
CITY:UPLANDSTATE: CAZIP CODE:
91784
CAPACITY:6CENSUS: 3DATE:
10/17/2022
UNANNOUNCEDTIME BEGAN:
01:24 PM
MET WITH:Almario QuizonTIME COMPLETED:
02:45 PM
ALLEGATION(S):
1
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9
Staff are not providing adequate supervision for resident in care.
Staff handled resident in a rough manner while in care.
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Natalie Ibarra and Paola Guerrero made an unannounced visit to the facility to investigate the above allegations. LPAs were greeted and allowed entrance by Direct Support Professional (DSP) Almario Quizon. Administrator Rhea Davalos was contacted and was unable to come to facility due to being out of town. The investigation consisted of interviews with pertinent parties.

The first allegation indicates staff are not providing adequate supervision for resident(s) in care. Interviews with Staff #1 (S!) and Staff #2 (S2) stated staff do provide adequate supervison to Client # 1 (C1). S1 and S2 stated C1 is able to go out on walks on their own and does not required supervision. S2 stated they do accompany C1 on walks in the morning and afternoon per C1's conservators request. Interview with C1's conservator stated C1 is very aware and is capable of going out in the community for walks alone. LPAs Interview C1's Case Mananger at Inland Regional Center (IRC) who stated as of recently they have recommended for C1 to go on walks with staff, but that C1 is still able to go out for walks on their own without staff.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Natalie Ibarra
LICENSING EVALUATOR SIGNATURE:

DATE: 10/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2022
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-20221011124034
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: SHAMROCK CARE HOME
FACILITY NUMBER: 361880720
VISIT DATE: 10/17/2022
NARRATIVE
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the second allegation states staff handled resident in a rough manner while in care. Interviews with S1 and S2 stated they have never witnessed staff handle C1 in a rough manner. Interview with C1 stated staff have never treated them in a rough manner.

Based on the information obtained, the allegations are UNSUBSTANTIATED. A finding of UNSUBSTANTIATED means that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur.

No deficiencies were cited during this visit.
An exit interview was conducted, and a copy of this report was provided to the DSP Almario Quizon
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Natalie Ibarra
LICENSING EVALUATOR SIGNATURE:

DATE: 10/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2