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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 366423467
Report Date: 09/22/2023
Date Signed: 09/22/2023 10:22:50 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/02/2020 and conducted by Evaluator Amy Goldenberg
COMPLAINT CONTROL NUMBER: 18-AS-20200602103008
FACILITY NAME:NEW DISCOVERY RESIDENTIAL SERVICES #5FACILITY NUMBER:
366423467
ADMINISTRATOR:BRYAN CLARDYFACILITY TYPE:
735
ADDRESS:33974 AVENUE "H"TELEPHONE:
(909) 570-9802
CITY:YUCAIPASTATE: CAZIP CODE:
92399
CAPACITY:4CENSUS: 3DATE:
09/22/2023
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Sharda Dawson, Caregiver
Vivian Francisco, Interum Administrator-Via telephone		TIME COMPLETED:
11:00 AM
ALLEGATION(S):
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Facility staff member caused injuries to resident.
INVESTIGATION FINDINGS:
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This unannounced visit conducted by Amy Goldenberg, Licensing Program Analyst (LPA), is to conclude this agency’s investigation into the complaint allegation mentioned above.

During the course of the investigation records were collected and reviewed, interviews were conducted, video surveillance of the incident and the San Bernardino Sherriff’s report regarding the incident were obtained. Review of the Surveillance video recorded revealed that S1 held C1 down and put a knee on their shoulder and/or head area. Interviews confirm the allegation. C1 complained of pain and had a bruise on their shoulder the following day. S1 was charged with two misdemeanor counts of Elder Abuse and an arrest warrant has been issued. The information collected has met the preponderance of evidence to validate the allegation of a facility staff member caused injury to a resident.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amy Goldenberg
LICENSING EVALUATOR SIGNATURE:

DATE: 09/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2023
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 18-AS-20200602103008
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: NEW DISCOVERY RESIDENTIAL SERVICES #5
FACILITY NUMBER: 366423467
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/22/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/25/2023
Section Cited
HSC
80072(a)(3)
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Personal Rights...each client shall have personal rights which include, but are not limited to, the following: To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse, or other actions of a punitive nature...
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Licensee will provide training to all employees in the area of personal rights from an outside educational provider. Verification of personal right training to be provided to CCL by POC due date if already conducted
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The facility has not met this requirement based on: as evidenced by video evidence that S1 held C1 down and put a knee on their shoulder and/or head area. This is a risk to the Health and Safety and personal rights violation of the residents in care.
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or verification that traniing has been scheduled with an outside educational vendor by POC due date, 24 hours from issue of this report.
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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: Nedra Brown
LICENSING EVALUATOR NAME: Amy Goldenberg
LICENSING EVALUATOR SIGNATURE:

DATE: 09/22/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3
Control Number 18-AS-20200602103008
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME: NEW DISCOVERY RESIDENTIAL SERVICES #5
FACILITY NUMBER: 366423467
VISIT DATE: 09/22/2023
NARRATIVE
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We have substantiated the complaint allegation as valid and that a violation has occurred based on the preponderance of available evidence. A copy of this report along with appeal rights are being reviewed with and furnished to the facility representative. Please see LIC 9099D.

** A Civil Penalty assessment accompanies the deficiency. The licensee has been informed that an enhanced civil penalty may be assessed based on Health and Safety Code 1569.49 after further review by the department.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amy Goldenberg
LICENSING EVALUATOR SIGNATURE:

DATE: 09/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3