361881026-2-8-2022-18-AS-EMAN-CDNS6Q-20220420133619

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 361881026
Report Date: 02/08/2022
Date Signed: 02/08/2022 01:29:19 PM

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
RIVERSIDE, CA 92507

This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/03/2022 and conducted by Evaluator Stephanie Williams

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20220203164419

FACILITY NAME:	HESPERIA SENIOR CARE		FACILITY NUMBER:	361881026
ADMINISTRATOR:	WANG, JIN A		FACILITY TYPE:	740
ADDRESS:	17583 SULTANA STREET		TELEPHONE:	(760) 669-0109
CITY:	HESPERIA	STATE: CA	ZIP CODE:	92345
CAPACITY:	18	CENSUS: 7	DATE:	02/08/2022
		UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Jin Wang		TIME COMPLETED:	12:45 PM

ALLEGATION(S):

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Illegal eviction

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Stephanie Williams made an unannounced visit to the facility in order to initiate a complaint investigation into the above allegation. LPA Williams identified herself to Administrator, Jin Wang, who was also informed of the purpose of the visit. The investigation consisted of records review and interviews with residents and staff.

LPA Williams interviewed Staff #1 (S1), who stated that Resident #1 (R1) was provided an eviction notice on January 9th 2022 for non-compliance of the facility rules. S1 stated that facility staff have spoken with R1's family members regarding R1's aggressive behaviors and have documented all incidences. S1 stated that R1 requires higher level of care and has reached out to another licensed facility who has agreed to accept R1 into their facility. S1 stated that R1 consented to being placed at another facility located in San Bernardino, CA. LPA Williams interviewed R1 who stated that when approached by facility staff regarding being placed at another facility, R1 stated that they wanted to speak to family members first. LPA Williams interviewed Family Member #1 (FM1) and Family Member #2 (FM2) who both stated that they felt they had no choice but to have

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 248-0337
LICENSING EVALUATOR NAME: Stephanie Williams	TELEPHONE: (951) 248-0317
LICENSING EVALUATOR SIGNATURE:	DATE: 02/08/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 18-AS-20220203164419

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
RIVERSIDE, CA 92507

FACILITY NAME: HESPERIA SENIOR CARE	FACILITY NUMBER: 361881026
	VISIT DATE: 02/08/2022

NARRATIVE

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R1 placed at another facility. LPA Williams reviewed documentation from S1, which appeared to be an eviction letter dated January 9th 2022. LPA Williams also reviewed documentation, such as R1's physician's report, which did not indicate R1 displayed aggressive behaviors. Documentation from other agencies also indicated that R1 did not display aggressive behaviors. LPA Williams reviewed the facility's rules which listed physical and verbal abuse as grounds for eviction from the facility. LPA Williams reviewed several incident reports which stated that R1 became aggressive with other residents in the facility and staff. Due to conflicting interviewee statements and lack of evidence to corroborate the allegation, the allegation is unsubstantiated.

Based on evidence obtained during today’s visit, LPA has determined that the above allegation 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 (LIC 9099) was discussed and a copy was provided to Wang at the conclusion of the visit.

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 248-0337
LICENSING EVALUATOR NAME: Stephanie Williams	TELEPHONE: (951) 248-0317
LICENSING EVALUATOR SIGNATURE:	DATE: 02/08/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2022

LIC9099 (FAS) - (06/04)

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