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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 366423587
Report Date: 07/01/2022
Date Signed: 12/14/2022 03:33:09 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
06/29/2022 and conducted by Evaluator Bernadette Allen
COMPLAINT CONTROL NUMBER: 56-AS-20220629105809
FACILITY NAME:SARAH JANE GUEST HOMEFACILITY NUMBER:
366423587
ADMINISTRATOR:MOLANO, NINAFACILITY TYPE:
740
ADDRESS:25488 NICKS AVENUETELEPHONE:
(909) 799-7501
CITY:LOMA LINDASTATE: CAZIP CODE:
92354
CAPACITY:6CENSUS: 2DATE:
07/01/2022
UNANNOUNCEDTIME BEGAN:
08:14 AM
MET WITH:Administrator-Nina MolamoTIME COMPLETED:
11:45 AM
ALLEGATION(S):
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Staff yell at residents in care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA)Bernadette Allen made an unannounced visit to investigate the above allegation, At 8:14 AM-LPA was granted entrance by the administrator Nina Malamo. LPA explained the above allegations.

Regarding the allegation “Staff yelled at resident” LPA interviewed facility staff and residents in the facility. All persons interviewed denied the allegation of staff yelling at the resident. The interviews conducted with residents and staff revealed that one of the residents living in the facility yells and makes outburst that are not directed towards anyone. The yelling heard in the facility is from one of the residents. There are no witnesses to corroborate that staff yells at residents. Therefore, based on interviews conducted the allegation "Staff yelled at resident" is UNSUBSTANTIATED.

A finding of unsubstantiated means although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur.

An exit interview where this report was discussed with the Licensee. A copy of this report was provided to the Nina Molamoat the conclusion of this investigation.


Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Bernadette AllenTELEPHONE: 951-897-2618
LICENSING EVALUATOR SIGNATURE:

DATE: 07/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2022
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 3
Control Number 56-AS-20220629105809
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: SARAH JANE GUEST HOME
FACILITY NUMBER: 366423587
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/01/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type A
07/01/2022
Section Cited
CCR
87355(e)(1)
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All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility....(1) Obtain a California clearance or a criminal record :.....
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The administrator will ensure that R3 will be associated by 7/5/2022.
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exemption as required by the Department.....This requirement is not met as evidenced by: Based on observation & file reiew the licensee failied to ensure that R3 had a criminal record clearance and associated to the facility prior to living in the residence.
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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.
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Bernadette AllenTELEPHONE: 951-897-2618
LICENSING EVALUATOR SIGNATURE:

DATE: 07/01/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 56-AS-20220629105809
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: SARAH JANE GUEST HOME
FACILITY NUMBER: 366423587
VISIT DATE: 07/01/2022
NARRATIVE
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Disregard this LIC9099-C this form was created in error.
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Bernadette AllenTELEPHONE: 951-897-2618
LICENSING EVALUATOR SIGNATURE:

DATE: 07/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3