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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 361880720
Report Date: 05/21/2024
Date Signed: 05/21/2024 01:34:25 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
02/07/2024 and conducted by Evaluator Paola Guerrero
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20240207113148
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:
05/21/2024
UNANNOUNCEDTIME BEGAN:
11:40 AM
MET WITH:Rhea Davalos-LicenseeTIME COMPLETED:
01:40 PM
ALLEGATION(S):
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Resident sustained a fracture while in care
Staff is verbally abusive to the clients while in care
Staff is intimidating the clients while in care
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Paola Guerrero conducted an unannounced visit to deliver findings on the allegation listed above. LPA met with Facility Licensee Rhea Davalos and explained the purpose of the visit. The investigation consisted of interviews and review of records.

First allegation, Resident sustained a fracture while in care. During interviews and review of records LPA observed that Client #1 rearranges furniture due to behavior. During record review LPA also observed that Inland Regional Center is aware if Client #1 behavior and indicated that the facility has being doing their best to re-direct client when exhibiting the behavior. During record review LPA observed that Client #1 sustained an injury on wrist however, based on record review and interviews neglect or abuse was not a contributing factor that led to Client #1 wrist injury. Because, of the rearranging of heavy furniture that Client #1 was doing that could have been the indicating factor as to how Client #1 sustained the wrist injury.

Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Paola Guerrero
LICENSING EVALUATOR SIGNATURE:

DATE: 05/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2024
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-20240207113148
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: 05/21/2024
NARRATIVE
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Second allegation, Staff is verbally abusive to the clients while in care. LPA conducted interviews with staff regarding the alleged allegation regarding verbal abuse, and all staff denied verbally abusing or witnessing staff verbally abuse clients in care. LPA conducted interview with Client #2 who indicated not being verbally abused by staff Client #2 also indicated not witnessing staff being verbally aggressing towards other clients in care.

Third allegation, Staff is intimidating the clients while in care. LPA conducted interviews with staff regarding the alleged allegation regarding intimidation, and all staff denied intimidating clients in care or witnessing staff to be intimidating clients while in care. LPA conducted interview with Client #2 who indicated not being intimidated by staff Client #2 also indicated not witnessing staff to be intimidating other clients in care. Based on the evidence obtained during the course of the investigation, LPA has determined that the above allegations are Unsubstantiated.

Unsubstantiated; meaning that 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 where this report (LIC 9099) was discussed, and a copy was provided to Facility Licensee Rhea Davalos.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Paola Guerrero
LICENSING EVALUATOR SIGNATURE:

DATE: 05/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2