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

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 361880989
Report Date: 03/24/2025
Date Signed: 03/24/2025 12:25:22 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO ASC, 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
01/09/2025 and conducted by Evaluator Becky Mann
COMPLAINT CONTROL NUMBER: 56-AS-20250109152502
FACILITY NAME:PEOPLE'S CARE SYCAMOREFACILITY NUMBER:
361880989
ADMINISTRATOR:ZIA PICKENSFACILITY TYPE:
737
ADDRESS:17358 SYCAMORE LANETELEPHONE:
(760) 961-1014
CITY:APPLE VALLEYSTATE: CAZIP CODE:
92307
CAPACITY:4CENSUS: 3DATE:
03/24/2025
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Davonna Mason, AdministratorTIME COMPLETED:
12:35 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff refused to seek medical attention for client in care
Staff did not administer client's medication as prescribed
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Becky Mann conducted an unannounced visit to the facility to initiate a complaint investigation. LPA met with Davonna Mason, Administrator and explained the purpose of the visit. The investigation consisted of LPA pertinent record reviews and interviews with staff and clients.

The allegation that staff refused to seek medical attention for client in care. Seven (7) staff interviewed denied refusing to seek medical attention for client in care. Two (2) clients interviewed stated that staff does seek medical attention for client in care.

The allegation that staff did not administer client’s medication as prescribed. Seven (7) staff interviewed denied not administering client’s medication as prescribed. Two (2) clients interviewed stated that staff does administer client’s medication as prescribed.

Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Becky Mann
LICENSING EVALUATOR SIGNATURE:

DATE: 03/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/24/2025
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-20250109152502
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: PEOPLE'S CARE SYCAMORE
FACILITY NUMBER: 361880989
VISIT DATE: 03/24/2025
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
Based on evidence obtained during this investigation, the allegation above is 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 was discussed and a copy of this report was provided to Davonna Mason, Administrator at the conclusion of the visit.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Becky Mann
LICENSING EVALUATOR SIGNATURE:

DATE: 03/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/24/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2