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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 366424311
Report Date: 12/09/2025
Date Signed: 12/09/2025 10:56:38 AM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO ASC, 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
09/10/2025 and conducted by Evaluator Becky Mann
COMPLAINT CONTROL NUMBER: 56-AS-20250910110714
FACILITY NAME:KAISER SPECIALIZED RESIDENTIAL MERLOTFACILITY NUMBER:
366424311
ADMINISTRATOR:DONTEE WEAVERFACILITY TYPE:
735
ADDRESS:21295 MERLOT LNTELEPHONE:
(760) 240-9976
CITY:APPLE VALLEYSTATE: CAZIP CODE:
92307
CAPACITY:4CENSUS: 2DATE:
12/09/2025
UNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Dontee Weaver, AdministratorTIME COMPLETED:
11:05 AM
ALLEGATION(S):
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9
Staff physically abuse client
Staff verbally abuse client
Staff did not assist client with care
Staff did not give medication as prescribed
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Becky Mann conducted an unannounced visit to the facility to initiate a complaint investigation. LPA met with Dontee Weaver, Administrator and discussed the purpose of the visit. The investigation consisted of LPA observations, pertinent record reviews and interviews with staff and clients.

The allegation that staff physically abuse client. LPA interviewed five (5) staff and they denied physically abusing the clients. Client #1 (C1) no longer resides at the facility as of 11/10/2025 based on the interview of Staff #1 (S1). Based on LPA observations, interviews and record reviews, C1 does not reside at the facility anymore. LPA interviewed Client #2 (C2) and Client #3 (C3) and they stated that staff have not physically abused them.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Becky Mann
LICENSING EVALUATOR SIGNATURE:

DATE: 12/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2025
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-20250910110714
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: KAISER SPECIALIZED RESIDENTIAL MERLOT
FACILITY NUMBER: 366424311
VISIT DATE: 12/09/2025
NARRATIVE
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The allegation that staff verbally abuse client. LPA interviewed five (5) staff and they denied verbally abusing the clients. LPA interviewed Client #2 (C2) and Client #3 (C3) and they stated that staff have not verbally abused them.

The allegation that staff did not assist client with care. LPA interviewed five (5) staff and they stated that they do assist clients with care. LPA interviewed Client #2 (C2) and Client #3 (C3) and they stated that staff do assist them with their care.

The allegation that staff did not give medication as prescribed. LPA interviewed five (5) staff and they stated that they do give clients their medication as prescribed. LPA reviewed (2) client medications and the Medication Administration Record (MAR). Based on LPA observations, interviews and record reviews the medications are labeled and administered as prescribed. LPA interviewed Client #2 (C2) and Client #3 (C3) and they stated that staff do give them their medication as prescribed.

Based on evidence obtained during this investigation, the allegation above is Unsubstantiated; meaning that 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.

An exit interview was conducted where this report was discussed, and a copy of this report was provided to Dontee Weaver, Administrator at the conclusion of the visit.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Becky Mann
LICENSING EVALUATOR SIGNATURE:

DATE: 12/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2