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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 366423474
Report Date: 11/16/2022
Date Signed: 11/16/2022 03:34:23 PM

Unsubstantiated


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
10/27/2022 and conducted by Evaluator Rayshaun Nickolas
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20221027161035
FACILITY NAME:VALLEY CRESTFACILITY NUMBER:
366423474
ADMINISTRATOR:JORDAN, KIMBERLYFACILITY TYPE:
740
ADDRESS:18524 CORWIN RDTELEPHONE:
(760) 242-3188
CITY:APPLE VALLEYSTATE: CAZIP CODE:
92307
CAPACITY:65CENSUS: 45DATE:
11/16/2022
UNANNOUNCEDTIME BEGAN:
02:29 PM
MET WITH:Kimberly Jordan, Executive DirectorTIME COMPLETED:
03:40 PM
ALLEGATION(S):
1
2
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8
9
Staff inappropriately touched resident
INVESTIGATION FINDINGS:
1
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5
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9
10
11
12
13
Licensing Program Analyst (LPA) Rayshaun Nickolas made an unannounced visit to the facility to deliver the finding on the above allegation. LPA met with Executive Director Kimberly Jordan and explained the purpose of the visit.

The investigation consisted of a file review and interviews with relevant parties. The allegation alleges that on October 26, 2022, client # 1 (C1) reported being inappropriately touched by staff #1 (S1) at the facility. C1 was taken to a hospital and examined; however, medical personnel did not observe any trauma or injuries to C1's body. Investigation into this incident reveals insufficient evidence to corroborate the allegation.

Based on the investigation, the above finding is Unsubstantiated. A finding of 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.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Rayshaun NickolasTELEPHONE: 951-255-9516
LICENSING EVALUATOR SIGNATURE:

DATE: 11/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2022
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 2
Control Number 56-AS-20221027161035
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: VALLEY CREST
FACILITY NUMBER: 366423474
VISIT DATE: 11/16/2022
NARRATIVE
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An exit interview was conduct where a copy of this report was provided.
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Rayshaun NickolasTELEPHONE: 951-255-9516
LICENSING EVALUATOR SIGNATURE:

DATE: 11/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2