366423474-8-9-2023-56-AS-EMAN-CV6N2P-20230829100505

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 366423474
Report Date: 08/09/2023
Date Signed: 08/09/2023 02:10:56 PM

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
07/18/2023 and conducted by Evaluator Mary Rico

PUBLIC

COMPLAINT CONTROL NUMBER: 56-AS-20230718134306

FACILITY NAME:	VALLEY CREST		FACILITY NUMBER:	366423474
ADMINISTRATOR:	JORDAN, KIMBERLY		FACILITY TYPE:	740
ADDRESS:	18524 CORWIN RD		TELEPHONE:	(760) 242-3188
CITY:	APPLE VALLEY	STATE: CA	ZIP CODE:	92307
CAPACITY:	65	CENSUS: 41	DATE:	08/09/2023
		UNANNOUNCED	TIME BEGAN:	12:49 PM
MET WITH:	Valerie Hammond		TIME COMPLETED:	02:10 PM

ALLEGATION(S):

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Facility is not purchasing needed supplies for residents.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Mary Rico conducted an unannounced visit to deliver findings on the allegation listed above. LPA met with Business Office Manager Valerie Hammond and explained the purpose of the visit. The investigation consisted of staff interviews, document reviews, and facility tour.

For allegation, Facility is not purchasing needed supplies for residents.

During interviews with staff, the staff stated the facility provides supplies for residents. S1 informed LPA that some residents receive their supplies from hospice and some residents receive supplies from their family. S1 stated the facility has supplies for residents located in the supply room. S1 and S2 informed LPA that some staff prefer to purchase their own supplies and will receive reimbursement from the facility.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 248-0337
LICENSING EVALUATOR NAME: Mary Rico	TELEPHONE: (951) 248-0293
LICENSING EVALUATOR SIGNATURE:	DATE: 08/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2023

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-20230718134306

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: VALLEY CREST	FACILITY NUMBER: 366423474
	VISIT DATE: 08/09/2023

NARRATIVE

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During interviews with residents, the residents stated that the facility does provide supplies for them.

During document review, LPA discovered that the facility purchases supplies for the residents every month. S2 provided supply and reimbursements receipts for LPA. S1 provided residents supply tracker.

During facility tour, LPA observed residents supplies in the supply room, and supplies in residents’ room.

Based on the evidence found during the investigation, the one (1) allegation listed above are deemed UNSUBSTANTIATED. A finding that the complaints are UNSUBSTANTIATED means although the allegation may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations 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 Business Office Manager Valerie Hammond, along with a copy of the appeal rights.

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 248-0337
LICENSING EVALUATOR NAME: Mary Rico	TELEPHONE: (951) 248-0293
LICENSING EVALUATOR SIGNATURE:	DATE: 08/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2023

LIC9099 (FAS) - (06/04)

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