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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 365530044
Report Date: 06/04/2026
Date Signed: 06/04/2026 01:52:19 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
, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/28/2026 and conducted by Evaluator Javier Prieto
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20260528104547
FACILITY NAME:BENNETT ADULT RESIDENTIAL IIFACILITY NUMBER:
365530044
ADMINISTRATOR:CHAVEZ, JOANNAFACILITY TYPE:
735
ADDRESS:13657 SYCAMORE LANETELEPHONE:
(909) 631-4332
CITY:CHINOSTATE: CAZIP CODE:
91710
CAPACITY:4CENSUS: 3DATE:
06/04/2026
UNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Joana Chavez, AdministratorTIME COMPLETED:
01:55 PM
ALLEGATION(S):
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Resident sustain unexplained injury
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Javier Prieto arrived to the facility arrive to the conduct a complaint investigation regarding the above allegation. LPA Prieto met with licensee Chavez and LPA explained the elements of the complaint.

Allegation #1 - LPA Prieto interviewed resident #1 (R1), in question, who states that she had fallen at the facility. LPA did not observe any apparent injuries to R1. LPA asked R1 if she was hit by staff or other residents causing an injuries. R1 stated no. LPA observed R2 at the facility at time of inspection. R2 is non verbal and able to respond to questions.

Administrator Chavez (S1) stated that R1 has had a recent visit to a medical facility regarding a separate medical matter, not related any injuries. S1 adds that R1 has had recent falls, which were documented, as well as medical facility visit and those reports were obtained for this investigation.
***continued on LIC 9099C***
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Javier Prieto
LICENSING EVALUATOR SIGNATURE:

DATE: 06/04/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/04/2026
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-20260528104547
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: BENNETT ADULT RESIDENTIAL II
FACILITY NUMBER: 365530044
VISIT DATE: 06/04/2026
NARRATIVE
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S1 states that falls have been occurring, recently, due to a change in medication. LPA obtained copies of the recent Psych assessment with R1.

Based on the information obtained there is not enough evidence that resident sustain unexplained injury. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. This report was signed by LPA Prieto and Administrator Chavez and a copy was left with the facility.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Javier Prieto
LICENSING EVALUATOR SIGNATURE:

DATE: 06/04/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/04/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 2