366413246-12-28-2022-56-AS-EMAN-CNLNP7-20230131093751

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 366413246
Report Date: 12/28/2022
Date Signed: 12/28/2022 11:27:48 AM

Unsubstantiated

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
12/22/2022 and conducted by Evaluator Ryan Gardner

PUBLIC

COMPLAINT CONTROL NUMBER: 56-AS-20221222110459

FACILITY NAME:	STERLING INN		FACILITY NUMBER:	366413246
ADMINISTRATOR:	BARBER, DONALD		FACILITY TYPE:	740
ADDRESS:	17738 FRANCESCA ROAD		TELEPHONE:	(760) 245-2999
CITY:	VICTORVILLE	STATE: CA	ZIP CODE:	92392
CAPACITY:	185	CENSUS: 116	DATE:	12/28/2022
		UNANNOUNCED	TIME BEGAN:	09:10 AM
MET WITH:	Donald Barber		TIME COMPLETED:	11:37 AM

ALLEGATION(S):

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Facility staff did not ensure that call system was working properly.
Facility staff did not inform resident's authorized person about resident's injury.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Ryan Gardner conducted an unannounced visit to the facility for the purpose of initiating an investigation and delivering findings for the above complaint allegations. LPA met with Administrator Donald Barber and explained the reason for the visit.

During today’s visit, LPA toured the facility, reviewed, and requested facility documents, interviewed staff members, and interviewed residents.

For allegation, Facility staff did not ensure that call system was working properly:

During interviews conducted with staff and residents, LPA found that the facility has a working call system. LPA was shown a demonstration in the resident’s bedrooms of how the call system works and how the staff responds and clears the call system.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 248-8222
LICENSING EVALUATOR NAME: Ryan Gardner	TELEPHONE: (951) 836-3180
LICENSING EVALUATOR SIGNATURE:	DATE: 12/28/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/28/2022

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-20221222110459

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: STERLING INN	FACILITY NUMBER: 366413246
	VISIT DATE: 12/28/2022

NARRATIVE

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For allegation, Facility staff did not inform resident's authorized person about resident's injury:

During document review, LPA found that resident R1 is self responsible, signs all their own financial and medical documents, and does not have a power of attorney document with the facility. The resident has family listed on an emergency call list and the facility will call to give the family updates on injuries unless the resident requests that a call isn’t made. R1 had a recent injury on 11/30/2022, on this day the facility contacted the family to inform them of the injury.

Based on the information found during the investigation, the allegations listed above are deemed UNSUBSTANTIATED.

A finding that the complaint is 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.

During today’s visit, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations.

An exit interview was conducted, and this report was discussed and provided to Administrator Donald Barber, along with a copy of the appeal rights.

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 248-8222
LICENSING EVALUATOR NAME: Ryan Gardner	TELEPHONE: (951) 836-3180
LICENSING EVALUATOR SIGNATURE:	DATE: 12/28/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/28/2022

LIC9099 (FAS) - (06/04)

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