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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 366411355
Report Date: 05/22/2025
Date Signed: 05/22/2025 04:16:24 PM

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
05/20/2025 and conducted by Evaluator Beena Singh
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20250520134712
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: 3DATE:
05/22/2025
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Facility Staff Mae TillettTIME COMPLETED:
04:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not prevent resident from being harmed by other residents.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Beena Singh conducted an unannounced visit to initiate and deliver findings on the allegations listed above. LPA met with Facility Staff Mae Tillett and explained the purpose of the visit. The investigation consisted of interviews, observations, and review of records.

First allegation: Staff did not prevent resident from being harmed by other residents.
Regarding the allegation stated above LPA conducted interviews with Client #1, Client #2, Client #3. regarding the allegation “Staff did not prevent resident from being harmed by other residents".

During the interviews three(3) out of three(3) clients denied being not looked after by the staff and all the clients stated they have always been supervised all the time by the staff in facility. In addition, three out of three clients denied being harmed by other residents. LPA conducted interviews with staff, and all denied the allegation along with witnessing staff let clients involve in altercation in care.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Beena Singh
LICENSING EVALUATOR SIGNATURE:

DATE: 05/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2025
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-20250520134712
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: PALMETTO FAMILY HOME
FACILITY NUMBER: 366411355
VISIT DATE: 05/22/2025
NARRATIVE
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5
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9
10
11
12
13
14
15
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20
21
22
23
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27
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32
Interviews conducted did not corroborate the allegation. Based on corroborating evidence obtained during the course of the investigation, LPA has determined that the above allegation is 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 Staff Mae Tillett.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Beena Singh
LICENSING EVALUATOR SIGNATURE:

DATE: 05/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2