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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 366410695
Report Date: 03/10/2022
Date Signed: 03/10/2022 12:11:00 PM

Unsubstantiated


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
, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/04/2022 and conducted by Evaluator Javier Prieto
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20220304104105
FACILITY NAME:EVERETT FOREST,LLCFACILITY NUMBER:
366410695
ADMINISTRATOR:ANGELO GALASINAOFACILITY TYPE:
740
ADDRESS:11350 POPLAR STTELEPHONE:
(909) 799-3170
CITY:LOMA LINDASTATE: CAZIP CODE:
92354
CAPACITY:6CENSUS: 4DATE:
03/10/2022
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Angelo GalasinaoTIME COMPLETED:
12:15 PM
ALLEGATION(S):
1
2
3
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5
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8
9
Unqualified staff caring for residents
Unqualified staff dispensing medication
Facility is not clean
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Javier Prieto arrived to the facility to conduct a complaint investigation regarding allegations that unqualified staff caring for residents, unqualified staff dispensing medication
and facility is not clean. LPA Prieto met with administrator Angelo Galasinao and discuss the details of the allegations made against the facility. Mr. Galasinao stated that he is the administrator with a current administrator certificate. Training that involves in obtaining such certificate includes dispensing medication and direct care for residents. Mr Galasinao was able to produce training documents related to these allegations and supplied LPA with copies. LPA Prieto toured the facility and found it to be clean and free from clutter and foul odors.
Based on the information obtained there is not enough evidence that unqualified staff caring for residents, unqualified staff dispensing medication and facility is not clean. Therefore, the allegations are deemed UNSUBSTANTIATED at this time. Although the allegations 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.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Javier Prieto
LICENSING EVALUATOR SIGNATURE:

DATE: 03/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
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