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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 366412345
Report Date: 03/28/2024
Date Signed: 03/28/2024 11:16:11 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
03/21/2024 and conducted by Evaluator Mary Rico
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20240321100558
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: 4DATE:
03/28/2024
UNANNOUNCEDTIME BEGAN:
08:55 AM
MET WITH:Francizrobert AbayaTIME COMPLETED:
11:30 AM
ALLEGATION(S):
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Staff did not prevent resident from leaving the facility unsupervised.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Mary Rico conducted an unannounced visit to investigate and deliver findings on the allegation listed above. LPA met with staff Francizrobert Abaya and explained the purpose of the visit. The investigation consisted of staff interviews, document reviews, and a facility tour.

For the allegation, Staff did not prevent resident from leaving the facility unsupervised.

LPA Rico conducted four (4) staff interviews. 2 out of the 4 staff informed LPA they were not working when C1 left the facility without supervision. 2 out of the 4 staff admitted they were not able to prevent C1 from leaving the facility without supervision because they did not notice C1 had left the facility. S1 informed LPA C1 was found at their neighbor's backyard and was returned to the facility.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Mary Rico
LICENSING EVALUATOR SIGNATURE:

DATE: 03/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2024
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 3
Control Number 56-AS-20240321100558
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: 03/28/2024
NARRATIVE
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During record review, LPA Rico reviewed C1 Individual Program Plan (IPP) which indicate R1 requires supervision at all times to ensure safety due to their wandering behavior and lack of safety awareness. In addition, LPA obtain video footage demonstrating there were not staff with C1 when they had entered their neighbor's back yard.

Based on the evidence gathered during today’s investigation, the one (1) allegation listed above are deemed SUBSTANTIATED. A finding that the complaints are SUBSTANTIATED means that the allegations are valid because the preponderance of evidence the standard has been met.

During today’s visit, one (1) Type A deficiency were cited per Title 22, Division 6, of the California Code of Regulations.

An exit interview was conducted, and this report (LIC9099) and (LIC9099D) was discussed and provided staff member Francizrobert Abaya along with a copy of the appeal rights.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Mary Rico
LICENSING EVALUATOR SIGNATURE:

DATE: 03/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 56-AS-20240321100558
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: 03/28/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/28/2024
Section Cited
CCR
85065(b)
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85065 Personnel Requirements
(b) The licensee shall employ staff as necessary to ensure provision of care and supervision to meet client needs. This requirement is not met as evidenced by:
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Licensee has agreed to send proof they have read and understood the regulation and will send proof they have trained all staff on the regulation cited above.
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 Based on evidence by interview and record review. The licensee did not comply with the section cited above by C1 leaving the facility without supervision which poses an immediate health, safety or personal rights risk to persons in care.
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POC due date 3/28/2024
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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: Mary Rico
LICENSING EVALUATOR SIGNATURE:

DATE: 03/28/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3