<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 366409901
Report Date: 02/21/2024
Date Signed: 02/21/2024 12:41:11 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 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
01/23/2024 and conducted by Evaluator Paola Guerrero
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20240123153228
FACILITY NAME:AMI-HOLLY HOUSEFACILITY NUMBER:
366409901
ADMINISTRATOR:VERGEL SANTOSFACILITY TYPE:
735
ADDRESS:15340 HOLLY DRIVETELEPHONE:
(909) 574-2577
CITY:FONTANASTATE: CAZIP CODE:
92335
CAPACITY:5CENSUS: 3DATE:
02/21/2024
UNANNOUNCEDTIME BEGAN:
11:31 AM
MET WITH:Vergel SantosTIME COMPLETED:
12:45 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not accord resident dignity in personal relationships with staff.
Staff yell at resident.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Paola Guerrero conducted an unannounced visit to deliver findings on the allegation listed above. LPA met with Facility Administrator Vergel Santons and explained the purpose of the visit. The investigation consisted of interviews and review of records.

First allegation, Staff did not accord resident dignity in personal relationships with staff. LPA conducted interviews with staff, LPA asked staff if client’s personal rights were being violated all indicated that no client’s personal rights are being violated. LPA asked staff if they have witnessed other staff violate the personal rights of a client, all denied witnessing other staff violate client’s personal rights. LPA conducted interviews with clients, LPA asked clients if their personal were being violated, clients indicated that their personal rights are not being violated by staff. LPA asked clients if they have witnessed staff violate client’s personal rights, all stated that they have not witnessed staff violate other client’s personal rights while in care.

Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Paola Guerrero
LICENSING EVALUATOR SIGNATURE:

DATE: 02/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/21/2024
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-20240123153228
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: AMI-HOLLY HOUSE
FACILITY NUMBER: 366409901
VISIT DATE: 02/21/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Second allegation, Staff yell at resident. LPA conducted interviews with staff LPA asked staff if clients are being yelled at or mistreated, all indicated that no staff is mistreating or yelling at clients in care. LPA asked staff if they have witnessed other staff mistreat or yell at clients while in care, all stated that they have not witnessed other staff mistreat or yell at clients in care. LPA conducted interviews with clients and asked clients if they are being mistreated or yelled at by staff, all clients denied being mistreated or yelled at by staff. Clients also denied witnessing staff yell or mistreat other clients in care. Based on the evidence obtained during the course of the investigation, LPA has determined that the above allegations are Unsubstantiated.

Unsubstantiated; meaning that 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 where this report (LIC 9099) was discussed, and a copy was provided to Facility Administrator Vergel Santos at the end of the visit.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Paola Guerrero
LICENSING EVALUATOR SIGNATURE:

DATE: 02/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/21/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2