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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 366412235
Report Date: 01/10/2025
Date Signed: 01/16/2025 01:38:40 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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7
8
9
Staff consume liquor while on shift
Staff lock facility doors to prevent residents from leaving
Staff insert suppositories to residents in care
Staff did not complete required trainings
Staff facility records are falsified
Staff did not maintain resident records
Residents are not provided proper food service
Staff did not ensure resident’s diapering needs were met
Staff did not inform resident’s physician of resident’s change of condition
INVESTIGATION FINDINGS:
1
2
3
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5
6
7
8
9
10
11
12
13
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 consume liquor while on shift, three (3) staff interviewed deny consuming liquor while on shift. Five (5) resident interviews reveal they have not witnessed staff consume liquor while on shift.

Regarding the allegation, staff lock the facility doors to prevent residents from leaving, three (3) staff interviewed deny locking the facility doors to prevent residents from leaving. Five (5) resident interviews reveal they have not witnessed staff lock facility doors to prevent them from leaving.

Regarding the allegation, staff insert suppositories to residents in care, three (3) staff interviewed deny inserting suppositories to residents in care. Five (5) resident interviews reveal they are not inserted with suppositories.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Magda MalcoreTELEPHONE: 951-248-0316
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 6
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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Regarding the allegation, residents are not provided proper food service, interviews with three (3) staff and four (5) residents reveal dinner is served 4:00 p.m. and breakfast is served between 6:30 a.m. and 7:00 a.m. Hours between the third meal and last meal are within regulation. Five (5) resident interviews reveal they are provided breakfast, lunch, and dinner. Four (4) out of five (5) resident interviews reveal they are provided snacks between meals.

Regarding the allegation, staff did not ensure resident’s diapering needs were met, three (3) staff interviewed deny not ensuring resident’s diapering needs were met. four (4) out of five (5) resident interviews reveal their diapering needs are met.

Regarding the allegation, staff did not inform resident’s physician of resident’s change of condition, three (3) staff interviews reveal they will notify the resident's doctor or nurse of any changes of resident's condition.

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.

SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Magda MalcoreTELEPHONE: 951-248-0316
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 6
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):
1
2
3
4
5
6
7
8
9
Staff did not complete required trainings
Staff facility records are falsified
Staff did not maintain resident records
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
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 complete required trainings, an LPA review of staff #1 (S1), staff #2 (S2), staff #3 (S3), and staff #4 (S4) files reveals that all four staff members have not completed their annual job training, including dementia and medication administration. S2 did not have any on-the-job training documentation on file for review. An interview with S2 reveals that they have been employed since 2023 and did not complete their CPR/first aid training until December 2024.

Regarding the allegation that staff facility records were falsified, LPA conducted a CPR/first aid certification verification for S1, S2, S3, and S4. The verification reveals that S1 and S4 certifications were not valid with the American Health Care Academy. LPA conducted a review of the health screenings (LIC 503) for S1, S2, S3, and S4.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Magda MalcoreTELEPHONE: 951-248-0316
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: 3 of 6
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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LPA's record review reveals that S1 and S2 had health screenings conducted by the same doctor at the same medical office with the same evaluation results, but conducted years apart. Additionally, LPA conducted a health screening verification through the medical office on record, and the verification reveals that no medical record was found for S2.

Regarding the allegation that staff did not maintain resident records, it was claimed that the facility did not have a current resident registry on file. LPA’s resident record review reveals that the facility did not have a resident registry available for LPA review.

Based on pertinent record review and interviews with relevant parties, the allegation is Substantiated. A finding that the complaint is Substantiated means that the allegation(s) is valid because the preponderance of the evidence standard has been met.
An exit interview was conducted where reports (LIC9099&LIC9099-D) were discussed and provided with appeal rights to Caregiver Salvatierra at the conclusion of the visit.
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Magda MalcoreTELEPHONE: 951-248-0316
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: 4 of 6
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/10/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/31/2025
Section Cited
CCR
87412(c)(1)(A)
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87412(c)Licensees shall maintain in the personnel records verification of required staff training...(1)The following staff training...shall be documented:(A)For staff who assist with personal activities of daily living, there shall be documentation of at least ten hours of initial training made within 4 weeks of employment and at least four hours of training annually thereafter in one or more of the content areas...This requirement is not met as evidenced by:
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The Licensee/Administrator shall provide proof current job training for S1, S2, S3, and S4 to the Licensing Agency for review by POC due date.
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The Licensee did not comply with the section cited above by no annual staff training on file;Which poses a potential health,safety or personal rights risk to persons in care.
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Type B
01/31/2025
Section Cited
CCR
87207
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87207 No licensee, officer or employee of a licensee shall make or disseminate any false or misleading statement regarding the facility...This requirement is not met as evidence by:
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The Licensee shall provide verifiable first aid/CPR training for S1 and S4 and verifiable Health screening documentation for S2 by POC due date.
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The Licensee did not comply with the section cited above by maintaining an invalid first aid certification for S1 and S4. By maintaining a nonverfiable health screening for S2 on file; Which poses a potential health,safety or personal rights risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Magda MalcoreTELEPHONE: 951-248-0316
LICENSING EVALUATOR SIGNATURE:

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

DATE: 01/10/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 6
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/10/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/31/2025
Section Cited
CCR
87508(b)
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(b) Registers of residents shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. Registers may be removed if necessary for copying...This requirement is not met as evidenced by:
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The Licensee/Administrator shall provide copy of registry to the licensing agency by POC due date.
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14
The Licensee did not comply with the section cited above by not having a resident registry on file for review; which poses a potential health,safety or personal rights risk to persons in care.
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7
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Magda MalcoreTELEPHONE: 951-248-0316
LICENSING EVALUATOR SIGNATURE:

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

DATE: 01/10/2025
LIC9099 (FAS) - (06/04)
Page: 6 of 6