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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 365530045
Report Date: 10/28/2025
Date Signed: 10/28/2025 03:10:35 PM

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
09/25/2025 and conducted by Evaluator Eldin Serrano
COMPLAINT CONTROL NUMBER: 56-AS-20250925093913
FACILITY NAME:JHOLLY SPRING VALLEY LAKE ADULT RESIDENTIAL HOMEFACILITY NUMBER:
365530045
ADMINISTRATOR:JOHNSON, LEE A.FACILITY TYPE:
735
ADDRESS:18520 CATAMARAN LANETELEPHONE:
(442) 255-4666
CITY:VICTORVILLESTATE: CAZIP CODE:
92395
CAPACITY:4CENSUS: 4DATE:
10/28/2025
UNANNOUNCEDTIME BEGAN:
02:25 PM
MET WITH:Debra Holly, Direct Support ProfessionalTIME COMPLETED:
03:20 PM
ALLEGATION(S):
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Staff yell at resident.
INVESTIGATION FINDINGS:
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On10/28/2025 at 2:25PM, Licensing Program Analysts (LPA) Eldin Serrano visited the facility to investigate the above mentioned allegation and deliver findings. LPA met with Direct Support Professional(DSP) Debra Holly to discuss the purpose of the visit.

The investigation involved interviews with all relevant parties regarding the allegation that facility staff yelled at a resident. The investigation revealed that staff #4 (S4) raised their voice at Client #1 (C1) in front of a group of individuals, as a method of redirection. This action was a violation of C1’s personal rights to be treated with dignity in their relationships with staff and others.

Based on interviews, the preponderance of evidence standard has been met, therefore, the allegation is substantiated under the California Code of Regulations (Title 22, Division 6 & Chapter 1).

An exit interview was conducted, where this report, LIC9099, LIC9099D along with appeal rights, was provided to the DSP Debra Holly.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Eldin Serrano
LICENSING EVALUATOR SIGNATURE:

DATE: 10/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2025
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 4
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
09/25/2025 and conducted by Evaluator Eldin Serrano
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20250925093913

FACILITY NAME:JHOLLY SPRING VALLEY LAKE ADULT RESIDENTIAL HOMEFACILITY NUMBER:
365530045
ADMINISTRATOR:JOHNSON, LEE A.FACILITY TYPE:
735
ADDRESS:18520 CATAMARAN LANETELEPHONE:
(442) 255-4666
CITY:VICTORVILLESTATE: CAZIP CODE:
92395
CAPACITY:4CENSUS: 4DATE:
10/28/2025
UNANNOUNCEDTIME BEGAN:
02:25 PM
MET WITH:Debra Holly, Direct Support ProfessionalTIME COMPLETED:
03:20 PM
ALLEGATION(S):
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9
Staff handled resident in a rough manner resulting in an injury.
Staff restrain resident in the room.
INVESTIGATION FINDINGS:
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On 10/28/2025 at 2:25 PM, Licensing Program Analyst (LPA) Eldin Serrano made an unannounced visit to the facility to investigate and deliver the findings of the above allegations. LPA Serrano met with Direct Support Professional (DSP) Debra Holly to explain the purpose of the visit. The investigation consisted of file review, interviews with facility staff, outside parties, and residents as well as facility observation.

Allegation: Staff handled a resident in a rough manner resulting in an injury. – Based on information received during staff and client’s interviews, 5 out of 6 staff and 4 out of 4 clients including client #1 (C1) stated that they did not witness/observe that staff #4 (S4) handled the client in a rough manner. LPA was unable to corroborate the allegation.

Allegation: Staff restrain resident in the room. - Based on interviews with staff and clients, all stated that S4 did not restrain C1 in C1’s room. LPA was unable to corroborate the allegation

*** Continuation in LIC9099C ***
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Eldin Serrano
LICENSING EVALUATOR SIGNATURE:

DATE: 10/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 56-AS-20250925093913
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: JHOLLY SPRING VALLEY LAKE ADULT RESIDENTIAL HOME
FACILITY NUMBER: 365530045
VISIT DATE: 10/28/2025
NARRATIVE
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Information received during investigation LPA did not find evidence to corroborate the allegations.

Based on the evidence, the allegations mentioned above are UNSUBSTANTIATED. A finding that the complaint is 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, therefore the allegation is unsubstantiated at this time.

An exit interview was conducted where this report, LIC9099 and LIC9099C were discussed and provided to DSP Debra Holly.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Eldin Serrano
LICENSING EVALUATOR SIGNATURE:

DATE: 10/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 56-AS-20250925093913
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: JHOLLY SPRING VALLEY LAKE ADULT RESIDENTIAL HOME
FACILITY NUMBER: 365530045
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/28/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/04/2025
Section Cited
CCR
80072(a)(1)
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80072(a)(1) Personal Rights
(a) Except for children’s residential facilities, each client shall have personal rights which include, but are not limited to, the following:(1)To be accorded dignity in his/her personal relationships with staff and other persons.

This requirement is not met as evidence by:
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The Licensee/Administrator agrees to read Title 22 section 80072 entirely, conduct training with all facility staff and submit proof of training with staff signatures by plan of correction (POC) due date.
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Based on observation and interviews the licensee did not comply with the section cited above by not ensuring that the client accorded dignity to his personal relationship with staff and other persons which poses a potential 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: Karen Clemons
LICENSING EVALUATOR NAME: Eldin Serrano
LICENSING EVALUATOR SIGNATURE:

DATE: 10/28/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 4