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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 365530069
Report Date: 05/20/2025
Date Signed: 05/20/2025 03:07:08 PM

Unsubstantiated


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
01/08/2024 and conducted by Evaluator Beena Singh
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20240108163512
FACILITY NAME:GRAPHITE HOME - SALEM CHRISTIAN HOMESFACILITY NUMBER:
365530069
ADMINISTRATOR:DAWSON, SHELLYFACILITY TYPE:
735
ADDRESS:4787 GRAPHITE CREED RD.TELEPHONE:
(909) 614-0575
CITY:JURUPA VALLEYSTATE: CAZIP CODE:
91752
CAPACITY:4CENSUS: 4DATE:
05/20/2025
UNANNOUNCEDTIME BEGAN:
01:01 PM
MET WITH:Home Administrator-Ronald Bautista TIME COMPLETED:
03:15 PM
ALLEGATION(S):
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Staff did not provide adequate supervision to a client.
Staff mishandled a client's medication while in care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Beena Singh made an unannounced visit to deliver findings for the allegations listed above. LPA stated the purpose of the visit, & was granted entry, and met with House Manager-Ronald Bautista. The investigation consisted of resident interviews, staff interviews, and document review.

Allegation #1, Staff did not provide adequate supervision to a client:
During staff interviews conducted by LPA Singh 4 out of 4 staff stated that Staff ensures clients are provided supervision to the clients. LPA Singh conducted client's interviews, 1 out of 2 residents stated staff do provide adequate supervision to clients. Staffing has been changed since this incident happened to ensure staff provides good care to the residents in care.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Beena Singh
LICENSING EVALUATOR SIGNATURE:

DATE: 05/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2025
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 2
Control Number 56-AS-20240108163512
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: GRAPHITE HOME - SALEM CHRISTIAN HOMES
FACILITY NUMBER: 365530069
VISIT DATE: 05/20/2025
NARRATIVE
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Allegation #2, Staff mishandled a client’s medication while in care.

During staff interviews conducted by department staff, 4 out of the 4 Staff stated that all staff had recent training on policies and procedures on medication, second staff double checks medication ensures medication are dispensed correctly. During clients’ interviews, 1 out of 2 client's stated staff provide medication while in care.

Based on the evidence found during the investigation, the allegations listed above are deemed UNSUBSTANTIATED. A finding that the complaints are UNSUBSTANTIATED means although the allegation may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. During today’s visit, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations.

An exit interview was conducted where this report (LIC 9099) was discussed, and a copy was provided to Facility Home Administrator Ronald Bautista at the end of the visit.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Beena Singh
LICENSING EVALUATOR SIGNATURE:

DATE: 05/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2