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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 366412235
Report Date: 01/10/2025
Date Signed: 01/10/2025 06:22:18 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
11/21/2024 and conducted by Evaluator Magda Malcore
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20241121094816
FACILITY NAME:D'VINE HOMEFACILITY NUMBER:
366412235
ADMINISTRATOR:CONCEPCION PANOPIOFACILITY TYPE:
740
ADDRESS:16123 VINE STREETTELEPHONE:
(760) 981-4595
CITY:HESPERIASTATE: CAZIP CODE:
92345
CAPACITY:10CENSUS: 7DATE:
01/10/2025
UNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Floredeliza SalvatierraTIME COMPLETED:
06:05 PM
ALLEGATION(S):
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Staff did not provide adequate medication assistance to residents in care
Staff refuse to call an ambulance for residents in care
Staff threatened residents in care
Staff did not ensure sufficient food items were available at the facility for residents in care
Staff did not prevent residents from engaging in inappropriate interactions
Staff yelled at residents in care
Staff did not assist residents that sustained falls
Staff are not following reporting requirements
Staff left residents unattended
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Magda Malcore conducted an unannounced visit to the facility conduct a complaint investigation on the above allegations. LPA met with Caregiver, Floredeliza Salvatierra, who was informed of today’s visit.

Regarding the allegation, staff did not provide adequate medication assistance to residents in care, three (3) staff interviewed deny not providing adequate medication assistance to residents in care. Five (5) resident interviews reveal they are provided with adequate medication assistance.

Regarding the allegation, staff refuse to call an ambulance for residents in care, three (3) staff interviewed deny refusing to call an ambulance for residents in care. Five (5) resident interviews reveal staff have not refuse to call an ambulance for them.

Regarding the allegation, staff threatened residents in care, three (3) staff interviewed deny threatening a resident in care.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Magda Malcore
LICENSING EVALUATOR SIGNATURE:

DATE: 01/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2025
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-20241121094816
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: D'VINE HOME
FACILITY NUMBER: 366412235
VISIT DATE: 01/10/2025
NARRATIVE
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Five (5) resident interviews reveal they have not been threatened by staff.

Regarding the allegation, staff did not ensure sufficient food items were available at the facility for residents in care, LPA observed the facility has the required supply of perishable and nonperishable foods at the facility. Three (3) staff interviewed deny not ensuring sufficient food items were available at the facility for residents in care. Five (5) resident interviews reveal staff serve an adequate quantity of food to meet their needs.

Regarding the allegation, staff did not prevent residents from engaging in inappropriate interactions, three (3) staff interviewed deny not preventing residents from engaging in inappropriate interactions. Five (5) residents interviews reveal that no other residents have engaged inappropriately towards them.

Regarding the allegation, staff yelled at residents in care, three (3) staff interviewed deny yelling at residents in care. Five (5) residents interviews reveal staff have not yelled at them.

Regarding the allegation, staff did not assist residents that sustained falls, three (3) staff interviewed deny not assisting residents that fall. Five (5) resident interviews reveal they have not fallen at the facility.

Regarding the allegation, staff are not following reporting requirements, three (3) staff interviewed deny not following reporting requirements.

Regarding the allegation, staff left residents unattended, three (3) staff interviewed deny leaving residents unattended. Five (5) resident interviews reveal that they have not been left alone without staff supervision.

Based on LPA observations, record review, and interviews with staff and resident, the above allegations are Unsubstantiated; meaning that although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur.

An exit interview was conducted where this report was discussed and copies with appeal rights were provided to Caregiver Salvatierra at the conclusion of the visit.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Magda Malcore
LICENSING EVALUATOR SIGNATURE:

DATE: 01/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2