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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 366409921
Report Date: 11/03/2021
Date Signed: 11/03/2021 10:24:18 AM



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
RIVERSIDE, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/13/2021 and conducted by Evaluator Melody Brown
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20210913135608
FACILITY NAME:MOUNTAIN VIEW RESIDENTIAL CAREFACILITY NUMBER:
366409921
ADMINISTRATOR:ILAGAN, ALEXANDERFACILITY TYPE:
740
ADDRESS:9073 OLIVE STTELEPHONE:
(909) 822-5174
CITY:FONTANASTATE: CAZIP CODE:
92335
CAPACITY:24CENSUS: 21DATE:
11/03/2021
UNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Nancy Keller/Nenita CarlosTIME COMPLETED:
10:45 AM
ALLEGATION(S):
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Sexual Abuse
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Melody Brown arrived at the facility to conclude a complaint investigation regarding allegation of sexual abuse. LPA Brown met with Community Liason Nenita Carlos and Caregiver Nancy Keller. Administrator Channe Carlos was contacted and unable to come to the facility.

The investigation included residents and staff interviews and file reviews. Based on interviews and records review conducted, LPA Brown cannot find evidence to corroborate the allegation. LPA Brown interviewed R1, and the information and details obtained were inconsistent. R1 reported the incident never occurred. There are no witnesses or medical documentation to corroborate the allegation of sexual abuse.

Based on the information obtained there is not enough evidence of allegation of sexual abuse. therefore, the allegation is deemed UNSUBSTANTIATED at this time.


Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 248-0337
LICENSING EVALUATOR NAME: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:

DATE: 11/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2021
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 18-AS-20210913135608
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
RIVERSIDE, CA 92507
FACILITY NAME: MOUNTAIN VIEW RESIDENTIAL CARE
FACILITY NUMBER: 366409921
VISIT DATE: 11/03/2021
NARRATIVE
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 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.

An exit interview was conducted with caregiver Nancy Keller, where this report, LIC 9099 were discussed and provided.
SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 248-0337
LICENSING EVALUATOR NAME: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:

DATE: 11/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 2