361880765-9-20-2023-56-AS-EMAN-CW5S52-20230929133337

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 361880765
Report Date: 09/20/2023
Date Signed: 09/20/2023 02:14:39 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
07/06/2023 and conducted by Evaluator Mary Rico

PUBLIC

COMPLAINT CONTROL NUMBER: 56-AS-20230706125956

FACILITY NAME:	ANITA CARE CENTER		FACILITY NUMBER:	361880765
ADMINISTRATOR:	JENNIFER BILIMORIA		FACILITY TYPE:	735
ADDRESS:	15121 RIVERSIDE LANE		TELEPHONE:	(951) 347-0887
CITY:	APPLE VALLEY	STATE: CA	ZIP CODE:	92307
CAPACITY:	5	CENSUS: 4	DATE:	09/20/2023
		UNANNOUNCED	TIME BEGAN:	01:57 PM
MET WITH:	Homeranthony Clavecillas		TIME COMPLETED:	02:20 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Client sustained bruises while in care.
Client reported sexual assault at the facility.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Mary Rico made an unannounced visit to the facility to conclude and issue findings for the investigation that was initiated on 8/3/2023. LPA stated the purpose of the visit and was granted entry and met with Homeranthony Clavecilla

For allegation, Client sustained bruises while care:

The investigation was conducted by IB Investigator which included a review of resident’s (C1,) consumer notes, and facility records. IB Investigator conducted interviews with C1 and S1.

During interviews with C1, C1 stated they have not had any accidents or recent falls. C1 did not have any bruises to show. C1 informed IB Investigator about being punched by another client (C2).

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Mary Rico
LICENSING EVALUATOR SIGNATURE:	DATE: 09/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2023

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 2

Control Number 56-AS-20230706125956

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: ANITA CARE CENTER	FACILITY NUMBER: 361880765
	VISIT DATE: 09/20/2023

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

During interview with S1, S1 stated C2 punched C1 on 6/1/2023 and only occurred once. S1 submitted a Special Incident Report that was sent to Community Care Licensing and to the Inland Regional Center. Documents were provided to IB Investigator.

For allegation, Client reported sexual assault at the facility.

During interviews with C1, C1 denied being touched inappropriately by anyone. C1 stated he gets along with caregivers.

During interviews with S1, S1 denied any knowledge of staff touching C1 inappropriately, S1 also denied that other clients may be touching C1 inappropriately. In addition, S1 informed IB investigator that C1 has made inappropriately sexual acts. S1 stated facility has been monitoring as part of their Individual Program Plan (IPP). Facility has documented behaviors on their daily notes. Documents were provided to IB Investigator.

Overall, during the investigation, there was not substantial evidence to collaborate the allegation.

Based on evidence obtained, the IB Investigator deemed the allegations listed above UNSUBSTANTIATED. A finding that the complaint is UNSUBSTANTIATED means although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur.

During today’s visit, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations.

An exit interview was conducted, and this report (LIC9099) was discussed and provided to Homeranthony Clavecilla, along with a copy of the appeal right.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Mary Rico
LICENSING EVALUATOR SIGNATURE:	DATE: 09/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 2