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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 366413166
Report Date: 06/06/2025
Date Signed: 06/06/2025 04:01:04 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO ASC, 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
05/02/2025 and conducted by Evaluator Renese Howell-Small
COMPLAINT CONTROL NUMBER: 56-AS-20250502152815
FACILITY NAME:PRECIOUS MOMENTS IFACILITY NUMBER:
366413166
ADMINISTRATOR:DE GUZMAN, RAMON CHITOFACILITY TYPE:
735
ADDRESS:16748 UKIAH STREETTELEPHONE:
(760) 596-0378
CITY:VICTORVILLESTATE: CAZIP CODE:
92345
CAPACITY:6CENSUS: DATE:
06/06/2025
UNANNOUNCEDTIME BEGAN:
12:55 PM
MET WITH:Administrator, Ramon De GuzmanTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Staff do not ensure residents' hygiene needs are being met
Staff do not ensure residents' dental needs are being met
Staff lock facility refrigerator
Staff are falsifying medication administration records
INVESTIGATION FINDINGS:
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On 06/06/2025 at 12:55PM Licensing Program Analyst (LPA) Renese Howell-Small conducted an unannounced visit to the facility in order to deliver findings for the above allegations. LPA discussed the purpose of the visit with Administrator, Ramon De Guzman. The investigation consisted of interviews and record review.
In regards to the allegation of staff do not ensure residents' hygiene needs are being met:
LPA interviewed five (5) staff and (2) residents. Staff state that they assist all of the residents with showering. The residents confirm that staff assist them with showering and they take showers daily. LPA observed three residents in care to have good hygiene. Based on interviews and observation, this allegation is UNSUBSTANTIATED.

In regards to the allegation of staff do not ensure residents' dental needs are being met:
LPA interviewed five (5) staff and two (2) residents. LPA reviewed the dental summary of all residents in care. Staff stated that they assist residents in tooth brushing and residents visit the dentist at least yearly. The residents confirm that they brush their teeth and staff assist them. Based upon interviews and record review, this allegation is UNSUBSTANTIATED.

Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Renese Howell-Small
LICENSING EVALUATOR SIGNATURE:

DATE: 06/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/06/2025
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 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO ASC, 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
05/02/2025 and conducted by Evaluator Renese Howell-Small
COMPLAINT CONTROL NUMBER: 56-AS-20250502152815

FACILITY NAME:PRECIOUS MOMENTS IFACILITY NUMBER:
366413166
ADMINISTRATOR:DE GUZMAN, RAMON CHITOFACILITY TYPE:
735
ADDRESS:16748 UKIAH STREETTELEPHONE:
(760) 596-0378
CITY:VICTORVILLESTATE: CAZIP CODE:
92345
CAPACITY:6CENSUS: DATE:
06/06/2025
UNANNOUNCEDTIME BEGAN:
12:55 PM
MET WITH:Administrator, Ramon De GuzmanTIME COMPLETED:
04:00 PM
ALLEGATION(S):
1
2
3
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9
Staff lock residents' closets
INVESTIGATION FINDINGS:
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13
On 06/06/2025 at 12:55PM Licensing Program Analyst (LPA), Renese Howell-Small, arrived facility unannounced to deliver findings of the complaint investigation into the allegations listed above. LPA met with Administrator, Ramon De Guzman; introduced self and stated purpose of the visit.

It is alleged that staff lock residents' closets.
LPA interviewed five (5) staff and two (2) residents. During the facility tour on 05/06/2025 LPA observed locked closets in each of the resident rooms. Staff stated that the closets are locked to safeguard each residents personal belongings. Based upon observation and interview, this allegation is SUBSTANTIATED.

A SUBSTANTIATED finding is defined as a violation has occurred based on the preponderance of available evidence.

An exit interview was conducted where this report LIC9099A, LIC9099D and Appeal Rights were discussed and a copy provided to Administrator, Ramon De Guzman.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Renese Howell-Small
LICENSING EVALUATOR SIGNATURE:

DATE: 06/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/06/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 56-AS-20250502152815
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: PRECIOUS MOMENTS I
FACILITY NUMBER: 366413166
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/06/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/13/2025
Section Cited
CCR
85088(3)
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85088 (3) Fixtures, Furniture, Equipment and Supplies (3) Portable or permanent closets and drawer space in each bedroom to accommodate the client's clothing and personal belongings.

This requirement is not met as evidenced as by:
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The licensee will remove the locks from the resident closets, install new locks and provide a key to each resident and send proof of purchase and installation along with the keys for the residents by the Plan of Correction due date. Staff will also work with residents on how to lock and unlock with their key.
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Based upon interview, observation and record review the licensee did not ensure that the residents have easy access to their personal belongings by locking the residents closets, which poses as a potential risk to the health and safety of residents in care. Only staff had the key to the residents closets.
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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: Karen Clemons
LICENSING EVALUATOR NAME: Renese Howell-Small
LICENSING EVALUATOR SIGNATURE:

DATE: 06/06/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/06/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 56-AS-20250502152815
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: PRECIOUS MOMENTS I
FACILITY NUMBER: 366413166
VISIT DATE: 06/06/2025
NARRATIVE
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In regards to the allegation of staff lock facility refrigerator :
LPA interviewed five (5) staff and two (2) residents. All staff denied locking the facility's refrigerator. LPA observed two refrigerators and one deep freezer to be without locks or any kind of locking mechanism. The residents stated that the refrigerators are not locked. Based on interviews and observation, this allegation is UNSUBSTANTIATED.

In regards to the allegation of staff are falsifying medication administration records:
LPA interviewed five (5) staff and (2) residents. LPA audited the facillity's Medication Administration Records (MAR) and medications and did not observe any errors. Staff stated that are trained in medication. They call the residents one by one and give them the medication and then mark the MAR. Staff denied falsifying the MAR. observed residents at a local evacuation site and interviewed eight (8) residents. Staff deny violating residents personal rights. Based on interviews, this allegation is UNSUBSTANTIATED.


UNSUBSTANTIATED is defined as the allegation may have happened or is valid, but there is not a preponderance of
the evidence to prove that the alleged violation occurred.

An exit interview was conducted where this report LIC9099 and LIC9099C was discussed and a copy was provided to Administrator, Ramon De Guzman.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Renese Howell-Small
LICENSING EVALUATOR SIGNATURE:

DATE: 06/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/06/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 4