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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 361881290
Report Date: 05/24/2023
Date Signed: 05/24/2023 12:00:30 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
, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/14/2022 and conducted by Evaluator Rayshaun Nickolas
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20221214112008
FACILITY NAME:GOLD DUST WAYFACILITY NUMBER:
361881290
ADMINISTRATOR:CREER, KEDRAFACILITY TYPE:
735
ADDRESS:12517 GOLD DUST WAYTELEPHONE:
(323) 395-8594
CITY:VICTORVILLESTATE: CAZIP CODE:
92392
CAPACITY:4CENSUS: 3DATE:
05/24/2023
UNANNOUNCEDTIME BEGAN:
11:21 AM
MET WITH:Patricia Woods, Administrator TIME COMPLETED:
12:10 PM
ALLEGATION(S):
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9
Facility was unable to transport clients due to facility vehicle not being in working order.
Administrator does not go to the facility.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Rayshaun Nickolas visited the facility announced to deliver the finding on the above allegations. LPA met with Patricia Woods and explained the purpose of the visit. The investigation included a facility tour, file reviews, and interviews with relevant parties.

Allegation #1 “Facility was unable to transport clients due to facility vehicle not being in working order”. The allegation alleged that sometime in September or October 2022, the facility's vehicle was in the shop for at least two (2) weeks. The clients had to reschedule their appointments because the facility did not provide an alternative vehicle. LPA Nickolas' interview with staff # 1 (S1) revealed that the facility's van was in the shop for a week and a half; however, the facility had use of the van used at another facility licensed by the Licensee. LPA Nickolas' interview with the Licensee revealed that the staff is insured to use their vehicles to transport residents under the facility's insurance policy. The Licensee stated that there were still other vehicles to drive, and the residents could still attend their outings, planned activities, and medical appointments. LPA Nickolas' file review confirmed that the facility's insurance policy provides insurance coverage for facility staff members to use their vehicles. The finding is Unsubstantiated. There is no evidence or witnesses to corroborate the allegation.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Rayshaun Nickolas
LICENSING EVALUATOR SIGNATURE:

DATE: 05/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2023
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 6
Control Number 56-AS-20221214112008
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: GOLD DUST WAY
FACILITY NUMBER: 361881290
VISIT DATE: 05/24/2023
NARRATIVE
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Allegation #2 “Administrator does not go to the facility”. The allegation alleged that the facility’s former administrator quit in August 2022, and the facility owner does not come to the facility. LPA Nickolas' interview with the Licensee revealed that after the former administrator quit, the Licensee took on the role of the facility’s administrator. The Licensee stated that the last time they were at the facility was on December 8, 2022, and that generally, when they stop by the facility, it is between 8:00 p.m. and 10:00 p.m. The Licensee stated they are always available if staff needs to contact them. LPA Nickolas' interviews with facility staff members revealed that the Licensee does visit the facility and is easily accessible. 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: 05/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 6
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
12/14/2022 and conducted by Evaluator Rayshaun Nickolas
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20221214112008

FACILITY NAME:GOLD DUST WAYFACILITY NUMBER:
361881290
ADMINISTRATOR:CREER, KEDRAFACILITY TYPE:
735
ADDRESS:12517 GOLD DUST WAYTELEPHONE:
(323) 395-8594
CITY:VICTORVILLESTATE: CAZIP CODE:
92392
CAPACITY:4CENSUS: 3DATE:
05/24/2023
UNANNOUNCEDTIME BEGAN:
11:21 AM
MET WITH:Patricia Woods, AdministratorTIME COMPLETED:
12:10 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff not meeting resident's needs due to inadequate staffing.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Rayshaun Nickolas visited the facility announced to deliver the finding on the above allegation. LPA met with Patricia Woods and explained the purpose of the visit. The investigation included a facility tour, file reviews, and interviews with relevant parties.

Allegation #1 “Staff not meeting resident's needs due to inadequate staffing”. The allegation alleged that the facility has four (4) clients with only one (1) staff working. LPA Nickolas’ interview with facility staff revealed one (1) staff member on duty per shift. LPA Nickolas' interview with the Licensee revealed one (1) staff on duty per shift. The Licensee stated that the COVID-19 waivers suspended the regional center staffing ratio. LPA Nickolas' interview with a representative of an outside agency revealed that Provider Information Notice 20-09-CCLD (PIN 20-09-CCLD) does not permit facilities to waive staff ratio requirements without written request and approval. Several Provider Information Notices (PINs) superseded PIN 20-09-CCLD. However, upon written request, facilities were permitted to waive staff ratio requirements through March 31, 2022. LPA Nickolas’ file review revealed that the Licensee did not comply with the PINs by not submitting a written request to waive their staff ratio.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Rayshaun Nickolas
LICENSING EVALUATOR SIGNATURE:

DATE: 05/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 56-AS-20221214112008
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: GOLD DUST WAY
FACILITY NUMBER: 361881290
VISIT DATE: 05/24/2023
NARRATIVE
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Based on the evidence gathered during the investigation, the above allegation is substantiated. A finding that the complaint is Substantiated means that the allegation(s) is valid because the preponderance of the evidence standard has been met.

An exit interview was conduct were a copy of this report (LIC 9099), LIC 9099D, and appeal rights were discussed and provide.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Rayshaun Nickolas
LICENSING EVALUATOR SIGNATURE:

DATE: 05/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 56-AS-20221214112008
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: GOLD DUST WAY
FACILITY NUMBER: 361881290
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/24/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/13/2023
Section Cited
CCR
85065.5
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85065.5 Day Staff-Client Ratio

(a) Whenever a client who relies upon others to perform all activities of daily living is present...
This requirement was not met, as evidenced by the following:
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The licensee shall read and submit a letter of understanding to the Regional Office (RO) by the POC due date. Licensee shall also maintain the staff-to-client ratio as outlined in regulations.
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Based on observation, interview, and file review, the Licensee did not ensure to maintain day staff-client ratio, which poses a health, safety, personal rights violation 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: Karen Clemons
LICENSING EVALUATOR NAME: Rayshaun Nickolas
LICENSING EVALUATOR SIGNATURE:

DATE: 05/24/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2023
LIC9099 (FAS) - (06/04)
Page: 6 of 6