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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 366412345
Report Date: 01/03/2024
Date Signed: 01/03/2024 10:54:45 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
11/17/2023 and conducted by Evaluator Paola Guerrero
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20231117080235
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:
01/03/2024
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Oliver DinerosTIME COMPLETED:
11:07 AM
ALLEGATION(S):
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Staff was under the influence while caring for the residents.
Staff did not provide timely assistance to resident.
Staff was sleeping while caring for the residents.
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 was under the influence while caring for the residents. During review of records (Police Incident Report), LPA observed that Staff #1 had self-admitted to reporting Law Enforcement Officer about consuming alcohol (Wine), while providing care to residents.

Second allegation, Staff did not provide timely assistance to resident. During review of records (Police Incident Report), LPA observed that Staff #1 informed to reporting Law Enforcement Officer that drinking wine while providing care had played a factor as to why Staff #1 had fallen asleep and prevented Staff #1 from hearing Resident #1 yelling for help.

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

DATE: 01/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/03/2024
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 4
Control Number 56-AS-20231117080235
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: 01/03/2024
NARRATIVE
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Third allegation, Staff was sleeping while caring for the residents. During Review of records (Police Incident Report), LPA observed that Staff #1 had consumed half a bottle of wine and had fallen asleep while providing care to residents. Based on the evidence gathered during the investigation, the above allegations are Substantiated.

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 (2); Health Related Services 85075 (b); and Night Supervision 85065.6 (b) (2), a from division 6, chapter, article 6, is being cited on the attached-
LIC 9099D.

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

DATE: 01/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/03/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 56-AS-20231117080235
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: 01/03/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/31/2024
Section Cited
CCR
80072(2)
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Personal Rights (2) to be accorded safe, healthful, and comfortable accommodations, furnishings, and equipment to meet his/her needs.

This requirement is not met as evidence by:


This requirement is not met as evidence by:
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Facility Administrator has agreed to review entire Personal Rights regulation and will provide training to all staff providing care regarding the importance of staff ethics, residents safety and wellbeing when providing care. Administrator will provide a signed copy of training and email the proof of training to LPA on POC due date 1/31/24.
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Based on review of record, facility staff did not ensure Resident #1 Personal Rights to be met, which poses an immediate Health, Safety, or Personal Rights risk to persons in care
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Type B
01/31/2024
Section Cited
HSC
85075(b)
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Health Related Services (b) The facility shall develop and implement a plan which ensures that assistance is provided to the clients in meeting their medical and dental needs.

This requirement is not met as evidence by:
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Facility Administrator has agreed to review entire Health Related Services regulation and will provide training to all staff providing care regarding the importance of providing care in a timely manner to all residents in care. Administrator will provide a signed copy of training and email the proof of training to LPA on POC due date 1/31/24.
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Based on review of record, facility staff did not ensure Resident #1 received immediate assistance when Resident #1 was yelling for help. 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: 01/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/03/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 56-AS-20231117080235
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: 01/03/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/31/2024
Section Cited
CCR
85065.6(b)(2)
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Night Supervision (b) Employees providing night supervision from 10:00 pm to 7:00 am, as specified in (c) through (f) below, shall be available ro assist in the care and supervision of clients in the event of an emergency, and shall have received the training in the following.... (2) First aid, as specified in section 80075.

This requirement is not met as evidence by:
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Facility Administrator has agreed to review entire Night Supervision regulation and will provide training to all staff providing care regarding the importance of providing immediate assistance to residents during emergencies. Administrator will provide a signed copy of training and email the proof of training to LPA on POC due date 1/31/24. Administrator will also develop and implement a plan that will ensure that the facility will have full night staffing support during the night shift when needed.
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Based on review of record, facility staff did not ensure to be available for Resident #1 during an emergency. 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: 01/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/03/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 4