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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 361881188
Report Date: 09/04/2025
Date Signed: 09/04/2025 11:56:15 AM

Substantiated


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
08/29/2025 and conducted by Evaluator Edith Conchas
COMPLAINT CONTROL NUMBER: 56-AS-20250829082419
FACILITY NAME:SPOELSTRA LLC DBA VOICE - REDLANDFACILITY NUMBER:
361881188
ADMINISTRATOR:YANES, TONIFACILITY TYPE:
775
ADDRESS:461 TENNESSEE ST STE R.TELEPHONE:
(909) 307-1600
CITY:REDLANDSSTATE: CAZIP CODE:
92373
CAPACITY:60CENSUS: 39DATE:
09/04/2025
UNANNOUNCEDTIME BEGAN:
09:35 AM
MET WITH:Director Toni YanezTIME COMPLETED:
12:15 PM
ALLEGATION(S):
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Client sustained unexplained/unreported injury.
INVESTIGATION FINDINGS:
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Licensing Program Analyst’s (LPA’s) Edith Conchas and Eldin Serrano conducted an unannounced visit to conduct a complaint investigation and to deliver findings on the allegations listed above. LPA met with Program Director Toni Yanez and explained the purpose of the visit. The investigation consisted of interviews, file reviews and observations.

Allegation: Client sustained unexplained/unreported injury. Regarding the first allegation “Client sustained unexplained/unreported injury.” LPA conducted an interview with staff 1 (S1) that picked up client from home to transfer to the Day program observed client with a red discoloration to left cheek and reported it to the Day program Director verbally at time of arrival. Staff 2 (S2) stated was made aware of the incident but did not treat the client because it appeared to be a rash like symptom and did not write any notes or incident reports.

Continue to LIC 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Edith Conchas
LICENSING EVALUATOR SIGNATURE:

DATE: 09/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/04/2025
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 3
Control Number 56-AS-20250829082419
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: SPOELSTRA LLC DBA VOICE - REDLAND
FACILITY NUMBER: 361881188
VISIT DATE: 09/04/2025
NARRATIVE
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During staff 3 (S3) interview it was revealed that S1 reported it to S3 and S3 observed the discoloration on the left cheek as well. S3 stated that it “didn’t seem like a big deal” it was not an injury. S3 gave verbal direction to keep an eye on it for the day to staff. Upon record reviews documentation did not include any reports of observation of rash-like appearance in the clients file regarding the observation of the client’s left cheek. Based on the evidence along with the observation, the above allegation is Substantiated.

Substantiated: A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Title 22 regulations, division 6, chapter 3, article 6, is being cited on the attached LIC 9099 D.

An exit interview was conducted where this report (LIC 9099) was discussed, and a copy was provided, along with a copy of the appeal rights to Program Director Toni Yanez.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Edith Conchas
LICENSING EVALUATOR SIGNATURE:

DATE: 09/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/04/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 56-AS-20250829082419
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: SPOELSTRA LLC DBA VOICE - REDLAND
FACILITY NUMBER: 361881188
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/04/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/12/2025
Section Cited
CCR
82061(a)
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82061Reporting Requirements(a) Upon the occurrence, during the hours the day program is providing services to the client, of any of the events specified in Section 82061(a)(1), a report shall be made... In addition, a written report containing the information specified in Section 82061(a)(2) shall be submitted to the licensing agency within seven days following the occurrence of the event.
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Facility director will submit a straff training signed by all staff and a statemnt of understanding to foloow the regualation 82061 (a).
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This requirement is not met as evidence by; Based on records reveiw, interviews with staff; S3 did not ensure to report the incident to licensing. Which poses a potential Health and Safety Risk of the clients in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Edith Conchas
LICENSING EVALUATOR SIGNATURE:

DATE: 09/04/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/04/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3