366412345-2-16-2023-56-AS-EMAN-CPH2BN-20230228161524

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 366412345
Report Date: 02/16/2023
Date Signed: 02/16/2023 12:37:39 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/11/2023 and conducted by Evaluator Anna Bueno

COMPLAINT CONTROL NUMBER: 56-AS-20230111103408

FACILITY NAME:	JUBILEE CARE HOMES		FACILITY NUMBER:	366412345
ADMINISTRATOR:	HERNANDEZ, NORMA		FACILITY TYPE:	735
ADDRESS:	1066 WINN DR		TELEPHONE:	(909) 755-1178
CITY:	UPLAND	STATE: CA	ZIP CODE:	91786
CAPACITY:	6	CENSUS: 3	DATE:	02/16/2023
		UNANNOUNCED	TIME BEGAN:	11:18 AM
MET WITH:	Oliver Dineros, Administrator		TIME COMPLETED:	12:40 PM

ALLEGATION(S):

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Client sustained injuries while in care
Client lost significant amount of weight while in care

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPAs) Anna Bueno and MAgda MAlcore conducted an unannounced visit to the facility to deliver findings on the complaint investigation of the above allegation. LPAs arrived at the facility at 9:46 AM but the facility was closed. LPAs waited for staff and met direct support provider (DSP) Soliman Co at 11:18AM who was informed of today’s visit. Administrator Oliver Dineros was phoned and arrived shortly.

Regarding allegation, "Client sustained injuries while in care": It is alleged that Client (C1) was observed to have a sore on big toe on left foot and one sore on ankle. Through investigation, C1 was found with wounds on foot. Dineros stated that blisters were observed on C1 however it is unknown how C1 got a blister. Dineros adds that C1's family was notified of the wounds. No Special Incident Reports (SIRs) were provided by facility to account for the blisters on C1's foot. LPAs were not able to find documenation that C1's wounds were observed prior to notifying C1's family.

Regarding allegation, "Client lost significant amount of weight while in care." Records reviewed reveal that Client 1 (C1) was last weighed at a medical facility in August 2022. C1 arrived at the facility in September 2022

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Anna Bueno
LICENSING EVALUATOR SIGNATURE:	DATE: 02/16/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 56-AS-20230111103408

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: JUBILEE CARE HOMES	FACILITY NUMBER: 366412345
	VISIT DATE: 02/16/2023

NARRATIVE

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and was seen by medical professional twice but C1 was not weighed during these visits. Facility records revealed that C1 was weighed once a month for four (4) months and was gaining and/or losing an average of 1-2 pounds. Client and staff interviews reveal that C1 has a good appetite and staff reached out to C1's family because it was observed that C1 was not gaining a substantial amount of weight.

Based on the information discovered during the investigation, the allegations are therefore unsubstantiated. A finding of UNSUBSTANTIATED means 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 with and a copy of this report was provided Mr. Dineros.

SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Anna Bueno
LICENSING EVALUATOR SIGNATURE:	DATE: 02/16/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2023

LIC9099 (FAS) - (06/04)

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