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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 366412235
Report Date: 09/10/2025
Date Signed: 09/10/2025 12:11:19 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
09/04/2025 and conducted by Evaluator Magda Malcore
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20250904132613
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: 9DATE:
09/10/2025
UNANNOUNCEDTIME BEGAN:
09:25 AM
MET WITH:Floredeliza SalvatierraTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Staff retaliated against a resident for reporting concerns
Staff are involuntarily transferring a resident to another facility
Facility does not maintain sample menu for resident review
Staff did not provide assistance to resident after fall
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Magda Malcore conducted an unannounced complaint visit to the facility. LPA met with Caregiver, Floredeliza Salvatierra and discussed the purpose for the visit.

Regarding the allegation, staff retaliated against a resident for reporting concerns, staff interviewed deny retaliating against a resident for reporting concerns. Four (4) residents interviewed deny that staff retaliated against them for reporting concerns.

Regarding the allegation, staff are involuntarily transferring a resident to another facility, staff interviewed deny that they are involuntarily transferring a resident to another facility. Four (4) residents interviewed deny that they are in the process of eviction or that staff are involuntarily transferring them to another facility.

Regarding the allegation, Facility does not maintain sample menu for resident review, LPA observed a weekly menu was posted on the kitchen refrigerator. (Continued on LIC9099-C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Magda Malcore
LICENSING EVALUATOR SIGNATURE:

DATE: 09/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2025
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-20250904132613
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: 09/10/2025
NARRATIVE
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Staff interviewed deny not maintaining a sample menu for residents to review. Three (3) out of four (4) residents interviews reveal that they have not requested to review the facility menu.

Regarding the allegation, Staff did not provide assistance to a resident after a fall, staff interviewed deny not providing assistance to a resident after a fall. Four (4) residents interviewed deny that staff have not assisted them after a fall.

Based on record review, interviews with staff and residents, the allegations are Unsubstantiated. 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 reports (LIC 9099 & LIC9099-C) were discussed, and a copy with appeal rights was provided to Caregiver Salvatierra at the conclusion of the visit.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Magda Malcore
LICENSING EVALUATOR SIGNATURE:

DATE: 09/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2