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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 366411355
Report Date: 11/01/2023
Date Signed: 11/01/2023 06:02:32 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
08/10/2023 and conducted by Evaluator Paola Guerrero
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20230810144443
FACILITY NAME:PALMETTO FAMILY HOMEFACILITY NUMBER:
366411355
ADMINISTRATOR:CARDEN, LORIFACILITY TYPE:
735
ADDRESS:9169 PALMETTO AVENUETELEPHONE:
(909) 854-5398
CITY:FONTANASTATE: CAZIP CODE:
92335
CAPACITY:6CENSUS: 5DATE:
11/01/2023
UNANNOUNCEDTIME BEGAN:
04:00 PM
MET WITH:LaPorsha GrantTIME COMPLETED:
06:15 PM
ALLEGATION(S):
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9
Staff hit client causing injuries
Staff tripped client
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Paola Guerrero conducted an unannounced visit to deliver findings on the allegations listed above. LPA met with Facility Manager LaPorsha Grant and explained the purpose of the visit.

First allegation, Staff hit client causing injuries. LPA conducted Interviews with Client #2, Client #3, Client #4, Client #5, and Client #6 and all clients denied being hit by staff or witnessing previous Client #1 (C1) being hit by staff in addition, all clients indicated to LPA that they feel safe and are not afraid of staff. LPA conducted interviews with Staff #1, Staff #2, and Staff #3, and all staff denied hitting residents or witnessing previous Client #1 (C1) being hit by staff.

Second allegation, staff tripped client. LPA conducted Interviews with Client #2, Client #3, Client #4, Client #5, and Client #6 and all clients denied being tripped by staff or witnessing previous Client #1 (C1) being tripped by staff. LPA conducted interviews with Staff #1, Staff #2, and Staff #3, and all staff denied tripping clients or witnessing Resident #1 (C1) being tripped by staff. Based on the evidence obtained during the course of the investigation, LPA has determined that the above allegations are Unsubstantiated.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Paola Guerrero
LICENSING EVALUATOR SIGNATURE:

DATE: 11/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2023
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-20230810144443
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: PALMETTO FAMILY HOME
FACILITY NUMBER: 366411355
VISIT DATE: 11/01/2023
NARRATIVE
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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 Laporsha Grant at the end of the visit.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Paola Guerrero
LICENSING EVALUATOR SIGNATURE:

DATE: 11/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2