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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 366424311
Report Date: 10/12/2023
Date Signed: 10/12/2023 02:57:55 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
09/14/2023 and conducted by Evaluator Mary Rico
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20230914150549
FACILITY NAME:KAISER SPECIALIZED RESIDENTIAL MERLOTFACILITY NUMBER:
366424311
ADMINISTRATOR:MILES, WILTONFACILITY TYPE:
735
ADDRESS:21295 MERLOT LNTELEPHONE:
(760) 240-9976
CITY:APPLE VALLEYSTATE: CAZIP CODE:
92307
CAPACITY:4CENSUS: 3DATE:
10/12/2023
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Chrishay HawkinsTIME COMPLETED:
03:15 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff do not adequately assist residents with activities of daily living.
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 staff Chrishay Hawkins and explained the purpose of the visit. The investigation consisted of staff interviews, client interviews, document reviews, and facility tour.

For allegation, Staff do not adequately assist residents with activities of daily living.

During interviews with staff, staff stated they assist clients with their ADLs. S1 informed LPA they help C1 and C2 with full assistance. S1 stated C3 is in independent but will assist if they request. S2 informed LPA they provide activities for clients such as: outings, board games, movies, walks in the community and nail spa. S2 informed LPA that C1 will refuse to attend some facility outings due to behaviors. S3 stated they assist clients throughout their shifts from dressing to preparing meals.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Mary Rico
LICENSING EVALUATOR SIGNATURE:

DATE: 10/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2023
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-20230914150549
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 MERLOT
FACILITY NUMBER: 366424311
VISIT DATE: 10/12/2023
NARRATIVE
1
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3
4
5
6
7
8
9
10
11
12
13
14
15
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18
19
20
21
22
23
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27
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32
During interviews with clients, clients stated staff will assist with their ADLs. C1 informed LPA their favorite activity is getting their nails done and reading books. C1 also stated, they prefer to stay in their room. C2 informed LPA they receive full assistance.

During facility tour, LPA observed activities for the clients, and received client’s physician report, consumer notes, and activity calendar.

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 Chrishay Hawkins, along with a copy of the appeal rights.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Mary Rico
LICENSING EVALUATOR SIGNATURE:

DATE: 10/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2