<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 361880981
Report Date: 06/29/2023
Date Signed: 06/29/2023 11:10:11 AM

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
09/02/2022 and conducted by Evaluator Rayshaun Nickolas
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20220902163350
FACILITY NAME:BLESSED DREAM HOMEFACILITY NUMBER:
361880981
ADMINISTRATOR:DINEROS, OLIVERFACILITY TYPE:
735
ADDRESS:13348 AVA LOMA WAYTELEPHONE:
(909) 996-2108
CITY:VICTORVILLESTATE: CAZIP CODE:
92392
CAPACITY:4CENSUS: 3DATE:
06/29/2023
UNANNOUNCEDTIME BEGAN:
09:06 AM
MET WITH:Siegfrido Villafranca, caregiverTIME COMPLETED:
11:15 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Neglect of Clients dental needs.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Rayshaun Nickolas visited the facility unannounced to deliver the finding on the above allegation. LPA met with caregiver Siegfrido Villafranca and explained the purpose of the visit. The investigation included file reviews and interviews with relevant parties.

The allegation alleged that on August 29, 2022, the reporting party (RP) was contacted by the dentist's office that treats resident #1 (R1) and informed that R1 had a month's worth of buildup on their teeth and would have to have their tooth pulled due to the condition. The allegation alleged that the dentist's office also advised the RP that they were concerned that R1 was not receiving adequate oral care. LPA Nickolas' interview with the Licensee revealed that the Licensee denied this allegation. The Licensee stated that the facility staff always attempts to assist R1 with brushing their teeth; however, R1 often refuses. LPA Nickolas' interview with staff #1 (S1) revealed that they always attempt to assist R1 in brushing their teeth, but R1 will refuse. LPA Nickolas' facility file review revealed that R1's behavioral assessments note that they refuse to brush their teeth.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Rayshaun Nickolas
LICENSING EVALUATOR SIGNATURE:

DATE: 06/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/29/2023
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-20220902163350
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: BLESSED DREAM HOME
FACILITY NUMBER: 361880981
VISIT DATE: 06/29/2023
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
 LPA Nickolas' facility file review revealed that R1's behavioral assessments note that they refuse to brush their teeth. LPA Nickolas' facility file review also revealed that a dentist sees all residents in care according to the dentist's recommendations. 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 copy of this report was provided.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Rayshaun Nickolas
LICENSING EVALUATOR SIGNATURE:

DATE: 06/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/29/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2