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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 365530101
Report Date: 12/05/2024
Date Signed: 12/05/2024 11:24:59 AM

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
10/10/2024 and conducted by Evaluator Raquel Hernandez
COMPLAINT CONTROL NUMBER: 56-AS-20241010143342
FACILITY NAME:512 CARE CENTERFACILITY NUMBER:
365530101
ADMINISTRATOR:ALVAREZ MENDOZA, MELVIN AFACILITY TYPE:
735
ADDRESS:512 W D ST.TELEPHONE:
(909) 983-1349
CITY:ONTARIOSTATE: CAZIP CODE:
91762
CAPACITY:4CENSUS: 2DATE:
12/05/2024
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Administrator Melvin MendozaTIME COMPLETED:
11:30 AM
ALLEGATION(S):
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9
Facility staff spoke inappropriately to resident.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Raquel Hernandez conducted an unannounced visit to deliver findings on the allegations listed above. LPA met with Administrator Melvin Mendoza and explained the purpose of the visit. The investigation consisted of staff interview and request of documentation.

For the allegation, Facility staff spoke inappropriately to resident.

LPA Hernandez conducted (4) staff interviews. During the staff interviews (4) out of the (4) staff stated they have not spoken inappropriate to any clients in care nor witnessed any staff speak inapprorpriately to clients in care.

LPA conducted (1) client interview. Client #1 (C1) stated facility has not mistreated them or spoke inappropriately to them.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Raquel Hernandez
LICENSING EVALUATOR SIGNATURE:

DATE: 12/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2024
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-20241010143342
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: 512 CARE CENTER
FACILITY NUMBER: 365530101
VISIT DATE: 12/05/2024
NARRATIVE
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Based on the evidence gathered during today’s investigation, the allegations listed above are deemed UNSUBSTANTIATED. A finding that the complaints are UNSUBSTANTIATED means although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

During today’s visit, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted, and this report (LIC9099) was discussed and provided to Administrator Melvin Mendoza.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Raquel Hernandez
LICENSING EVALUATOR SIGNATURE:

DATE: 12/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2