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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 366423695
Report Date: 03/22/2022
Date Signed: 03/22/2022 02:08:00 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
, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/17/2022 and conducted by Evaluator Ryan Gardner
COMPLAINT CONTROL NUMBER: 56-AS-20220317083533
FACILITY NAME:SALVEREY CAREFACILITY NUMBER:
366423695
ADMINISTRATOR:MARIA V. SALEFACILITY TYPE:
740
ADDRESS:939 E. BANYAN STREETTELEPHONE:
(909) 947-6153
CITY:ONTARIOSTATE: CAZIP CODE:
91761
CAPACITY:0CENSUS: 0DATE:
03/22/2022
ANNOUNCEDTIME BEGAN:
01:50 PM
MET WITH:Maria Sale-LicenseeTIME COMPLETED:
02:17 PM
ALLEGATION(S):
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Food services were inadequate.
Not enough staff to meet resident's needs.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Ryan Gardner conducted an announced office visit to conclude the investigation to the above allegations.

Allegation #1: “Food services were inadequate”

Based on interviews conducted with an outside a party and the licensee it was revealed that the allegation occurred from 2/14/2021 to 2/15/2022. LPA learned that the residents living in the facility during that time period no longer reside at this facility therefore could not be interviewed. During the interview with the licensee, Ms. Sale admitted that the food quality at the facility was not acceptable. Ms. Sale admitted that the food fed to the residents was in small quantities, which left residents searching for food in the kitchen cabinets.

Continued on LIC 9099-C ...
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Ryan GardnerTELEPHONE: (951) 836-3180
LICENSING EVALUATOR SIGNATURE:

DATE: 03/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2022
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-20220317083533
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: SALVEREY CARE
FACILITY NUMBER: 366423695
VISIT DATE: 03/22/2022
NARRATIVE
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Allegation #2: “Not enough staff to meet resident’s needs”

Based on interviews conducted with an outside party and the licensee it was revealed that the allegation occurred from 2/14/2021 to 2/15/2022. LPA learned that the residents living in the facility during that time period no longer reside at this facility therefore could not be interviewed. During the interview with the licensee, Ms. Sale admitted that there was not enough staff to meet the resident’s needs. Ms. Sale stated that one (1) caretaker was not enough to provide care for five (5) residents.

Based on the information provided by the licensee, the above allegations are SUBSTANTIATED. The facility is being cited for two (2) deficiencies per Title 22, Division 6, of the California Code of Regulations.

An exit interview was conducted where this report was discussed and provided to Ms. Sale, along with a copy of the 9099-D form and the appeal rights.
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Ryan GardnerTELEPHONE: (951) 836-3180
LICENSING EVALUATOR SIGNATURE:

DATE: 03/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 56-AS-20220317083533
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: SALVEREY CARE
FACILITY NUMBER: 366423695
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/22/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/22/2022
Section Cited
CCR
87555(a)
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General Food Service Requirements. The total daily diet shall be of the quality and in the quantity necessary to meet the needs of the residents and shall meet the Recommended Dietary Allowances of the Food and Nutrition Board of the National Research Council. All food shall be selected, stored, prepared and served in a safe and healthful manner.
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The plan of correction does not need to take place due to the facility being closed as of 2/15/2022.
Type A
03/22/2022
Section Cited
CCR
87411(a)
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Personnel Requirements - General. Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs...Additional staff shall be employed as necessary... The licensing agency may require any facility to provide additional staff whenever it determines...
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The plan of correction does not need to take place due to the facility being closed as of 2/15/2022.
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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: Ryan GardnerTELEPHONE: (951) 836-3180
LICENSING EVALUATOR SIGNATURE:

DATE: 03/22/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3