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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 361881267
Report Date: 04/25/2025
Date Signed: 04/25/2025 10:30:41 AM

Substantiated


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
10/27/2023 and conducted by Evaluator Paola Guerrero
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20231027133450
FACILITY NAME:HANSEN RESIDENTIAL CAREFACILITY NUMBER:
361881267
ADMINISTRATOR:CLARKE, ZOIEFACILITY TYPE:
735
ADDRESS:374 S. VAN NESS AVE.TELEPHONE:
(909) 608-1699
CITY:UPLANDSTATE: CAZIP CODE:
91786
CAPACITY:4CENSUS: 3DATE:
04/25/2025
UNANNOUNCEDTIME BEGAN:
09:17 AM
MET WITH:Zoie ClarkeTIME COMPLETED:
11:00 AM
ALLEGATION(S):
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Staff hit resident causing multiple bruising.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Paola Guerrero provided Licensee/Facility Administrator Zoie Clarke with complaint investigative report following Department investigation of allegation that staff hit C1 causing multiple bruising. The Investigation consisted of observations, records review, and interviews with relevant parties.

Based upon investigation, it was revealed that on or around October 26, 2023, C1 was observed with multiple bruises and contusions to various areas of C1 body including bruising on chest area, abrasion to the right side of rib, multiple bruising and contusions to the right thigh and buttocks, multiple bruising and contusions to the left thigh and buttocks, bruising and contusion to the lower left thigh, an abrasion to the left lower back. Interviews revealed that around a week prior to October 26, 2023, C1 was observed to be hit by Staff #1 (S1) with what was described as a black baseball bat.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Paola Guerrero
LICENSING EVALUATOR SIGNATURE:

DATE: 04/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2025
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-20231027133450
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: HANSEN RESIDENTIAL CARE
FACILITY NUMBER: 361881267
VISIT DATE: 04/25/2025
NARRATIVE
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Investigation also revealed that S1 was known to carry a black baseball bat. Investigation further revealed that the injuries sustained by C1 looked consistent to be caused by “an elongated blunt force object similar to a bat.” As a result of investigation, the allegation that staff hit C1 causing multiple bruising, similarly contusions, is substantiated.

A substantiated finding means that the allegation is valid because the preponderance of the evidence standard has been met. Licensee is cited per California Code of Regulations, Title 22. In addition, licensee is assessed an immediate civil penalty of five hundred dollars ($500) for violation that resulted in the injury or illness of a person in care. In addition, an additional review is being conducted and additional civil penalty may be imposed per Health and Safety Code 1548 (f)(1)(A).

Exit interview was conducted and copy of report was provided to Facility Licensee/Administrator Zoie Clarke. Appeal rights were explained, and copy was provided.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Paola Guerrero
LICENSING EVALUATOR SIGNATURE:

DATE: 04/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Citations on this Visit Report are Under Appeal!

Control Number 56-AS-20231027133450
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: HANSEN RESIDENTIAL CARE
FACILITY NUMBER: 361881267
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/25/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Under Appeal
Type A
04/28/2025
Section Cited
CCR
80072(a)(3)
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Personal Rights : Except for children’s residential facilities, each client shall have personal rights which include, but are not limited to, the following: To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse…This requirement is not met as evidenced by:
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The Licensee has agreed to read over the "Personal Rights 80072(a)(3)" regulation and provide training to all staff regarding Personal Rights of clients in care. Licensee will provide a training of understanding signed and dated by all staff and email a copy to LPA Guerrero by POC date of 4/28/2025.
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Based on observations, interviews, and record review, Licensee did not afford C1 personal rights. S1 hit C1 causing multiple bruises to various areas of C1 body including thighs, buttocks, chest, rib, and back. This poses an immediate health, safety, or personal rights risk to persons 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: Efren Malagon
LICENSING EVALUATOR NAME: Paola Guerrero
LICENSING EVALUATOR SIGNATURE:

DATE: 04/25/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3