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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 366412345
Report Date: 10/02/2023
Date Signed: 10/02/2023 09:55:27 AM

Substantiated


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
08/29/2023 and conducted by Evaluator Paola Guerrero
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20230829161451
FACILITY NAME:JUBILEE CARE HOMESFACILITY NUMBER:
366412345
ADMINISTRATOR:HERNANDEZ, NORMAFACILITY TYPE:
735
ADDRESS:1066 WINN DRTELEPHONE:
(909) 755-1178
CITY:UPLANDSTATE: CAZIP CODE:
91786
CAPACITY:6CENSUS: 3DATE:
10/02/2023
UNANNOUNCEDTIME BEGAN:
09:08 AM
MET WITH:Oliver DinerosTIME COMPLETED:
10:00 AM
ALLEGATION(S):
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Staff intimidated client
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Paola Guerrero conducted an unannounced visit to deliver findings on the allegation listed above. LPA met with Facility Administrator Oliver Dineros and explained the purpose of the visit. The investigation consisted of interviews and a review of records.

First allegation, Staff intimidated client. During interview with Resident #1 (R1) authorized representative, it was discovered based on videos provided by Resident #1 how Staff #1 was having a heated discussion with Resident #1 and at one point Staff #1 got really close to Resident #1. Authorize representative also indicated that in second video an unknown staff was heard in the background calling Resident #1 a “Bully”. LPA stated to facility staff that such behavior towards Resident #1 was inappropriate and handled incorrectly. LPA advised staff that verbal intervention to verbally de-escalate disruptive behaviors towards residents should be applied to prevent further escalation with residents. Based on the evidence gathered during the investigation, the above allegations are Substantiated.

Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Paola Guerrero
LICENSING EVALUATOR SIGNATURE:

DATE: 10/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2023
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 3
Control Number 56-AS-20230829161451
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: JUBILEE CARE HOMES
FACILITY NUMBER: 366412345
VISIT DATE: 10/02/2023
NARRATIVE
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Substantiated A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Title 22 regulations, Personal Rights 80072 (1), from division 6, chapter, article 6, is being cited on the attached LIC 9099 D.

An exit interview was conducted where this report (LIC 9099) was discussed, and a copy was provided to Facility Administrator Oliver Dineros at the end of the visit.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Paola Guerrero
LICENSING EVALUATOR SIGNATURE:

DATE: 10/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 56-AS-20230829161451
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: JUBILEE CARE HOMES
FACILITY NUMBER: 366412345
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/02/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/27/2023
Section Cited
CCR
80072(1)
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Personal Rights (1) To be accorded dignity in his/her personal relationship with staff and other persons.

This requirement is not met as evidence by:
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Lincesee has agreed to read over entire personal rights regulation and conduct a training on the understanding of personal rights. Lincesee will provide traning sign in sheet demonstrating that all staff working at the facility has taken the traning on POC date of 10/27/2023. Traning will be emailed to assigned LPA.
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Based on observation, interviews and record review, the licensee did not ensure personal rights was obtain for 1 of 1 client in care, which poses an immediate 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.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Paola Guerrero
LICENSING EVALUATOR SIGNATURE:

DATE: 10/02/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3