366423474-12-9-2021-18-AS-EMAN-CCSR9N-20220323124950

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 366423474
Report Date: 12/09/2021
Date Signed: 12/09/2021 01:57:23 PM

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
RIVERSIDE, CA 92507

This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/06/2021 and conducted by Evaluator Melody Brown

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20211206102656

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: 31	DATE:	12/09/2021
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Kimberly Jordan		TIME COMPLETED:	02:05 PM

ALLEGATION(S):

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Staff did not have resident sign documents
Staff did not notify residents authorized representative of documents that needed to signed

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPAs) Melody Brown and Bernadette Allen conducted an unannounced visit to the facility to commence a complaint investigation. LPAs were greeted and granted entrance at the reception area. LPAs Brown and Allen met with Administrator Kimberly Jordan and identified themselves and discussed the purpose of the visit and the elements of the allegation.

LPAs Brown and Allen interviewed Administrator, residents, and staffs as well as reviewed and obtained facility records. Throughout the investigation process, it was found that the allegation #1 Staff did not have resident sign documents is UNSUBSTANTIATED. Based on the fact that through consistent interviews with staffs, and residents indicated that resident #1 (R1) refused to sign document. 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, therefore the allegation is UNSUBSTANTIATED.

***********Continues on LIC 9099-C********************

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 248-0337
LICENSING EVALUATOR NAME: Melody Brown	TELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:	DATE: 12/09/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2021

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 18-AS-20211206102656

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
RIVERSIDE, CA 92507

FACILITY NAME: VALLEY CREST	FACILITY NUMBER: 366423474
	VISIT DATE: 12/09/2021

NARRATIVE

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Regarding allegation #2- Staff did not notify resident’s authorized representative of documents that needed to be signed. LPAs Brown and Allen interviewed Administrator, residents, and staffs as well as reviewed facility records. Throughout the investigation process, it was found that allegation #2 Staff did not notify resident’s authorized representative of documents that needed to be signed is UNSUBSTANTIATED. Interviews with staffs and residents indicated that the facility was in constant communication with resident #1 (R1) proposed Conservator from 10/26/2021 and continuing and proposed Conservator was informed of receipts of legal documents last 11/182021 and documents were emailed to law firm per proposed conservator request. LPAs confirmed that no delayed of documents occurred. 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, therefore the allegation is UNSUBSTANTIATED.

An exit interview was conducted where this report was discussed and provided to Administrator Kimberly Jordan.

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 248-0337
LICENSING EVALUATOR NAME: Melody Brown	TELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:	DATE: 12/09/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2021

LIC9099 (FAS) - (06/04)

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