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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 366424116
Report Date: 05/10/2024
Date Signed: 05/10/2024 03:16:55 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
01/18/2024 and conducted by Evaluator Mary Rico
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20240118103150
FACILITY NAME:KAISER SPECIALIZED RESIDENTIAL IVANPAHFACILITY NUMBER:
366424116
ADMINISTRATOR:CARSON, STEPHANIEFACILITY TYPE:
735
ADDRESS:14180 IVANPAH RDTELEPHONE:
(760) 946-3096
CITY:APPLE VALLEYSTATE: CAZIP CODE:
92307
CAPACITY:4CENSUS: 3DATE:
05/10/2024
UNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Administrator Jamel CarrollTIME COMPLETED:
02:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff got into an altercation with resident
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Mary Rico conducted an unannounced visit to deliver findings on the allegation listed above. LPA met with Administrator Jamel Carroll and explained the purpose of the visit. The investigation consisted of staff interviews, client interviews and document reviews.

For the allegation, Staff got into an altercation with resident.

LPA Rico conducted five (5) staff interviews. 5 out of the 5 staff informed LPA that no staff has been in an altercation with a resident. 3 out of the 5 staff informed LPA that C1 has behaviors where he can be aggressive towards the staff. S1 stated that C1 recently had a behavior where he punched a staff member without a reason.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Mary Rico
LICENSING EVALUATOR SIGNATURE:

DATE: 05/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2024
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-20240118103150
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: KAISER SPECIALIZED RESIDENTIAL IVANPAH
FACILITY NUMBER: 366424116
VISIT DATE: 05/10/2024
NARRATIVE
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5
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32
In addition, LPA conducted 2 client interviews. C1 admitted no staff has been in a altercation with them. C1 also admitted punching a staff member without a reason. 2 out of 2 clients stated the staff provide good care.

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 Administrator Jamel Caroll.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Mary Rico
LICENSING EVALUATOR SIGNATURE:

DATE: 05/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2