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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 366424311
Report Date: 08/13/2024
Date Signed: 08/13/2024 03:50:51 PM

Substantiated


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
12/11/2023 and conducted by Evaluator Mary Rico
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20231211135043
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:
08/13/2024
UNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Aaliyah DukeTIME COMPLETED:
04:15 PM
ALLEGATION(S):
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Staff did not provide adequate care and supervision to the clients.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Mary Rico conducted an unannounced visit to deliver findings on the allegation listed above. LPA met with staff Aaliyah Duke and explained the purpose of the visit. The investigation consisted of staff interviews, client interviews, document reviews, and facility tour.

For the allegation, Staff did not provide adequate care and supervision to the clients.

During staff interview, 5 out of the 6 staff stated that S1 and S2 were not providing adequate care and supervision. S1 admitted they were unable to provided C1 one on one care due to dying their hair inside the facility bathroom with S2. 5 out of the 6 staff stated C1 requires one on one care.

During record review, on C1 Person Centered Assessment 2024 indicated that C1 requires one to one care.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Mary Rico
LICENSING EVALUATOR SIGNATURE:

DATE: 08/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2024
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 3
Control Number 56-AS-20231211135043
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: 08/13/2024
NARRATIVE
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During client interviews, 1 out of the 3 clients stated S1 and S2 were not able to provide supervision because they were dying their hair inside the facility bathroom.

Based on the evidence gathered during today’s investigation, the one (1) allegation listed above are deemed SUBSTANTIATED. A finding that the complaints are SUBSTANTIATED means that the allegation are valid because the preponderance of evidence the standard has been met.

During today’s visit, one (1) deficiency were cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted, and this report (LIC9099) and LIC9099D was discussed and provided to staff Aaliyah Duke along with a copy of the appeal rights.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Mary Rico
LICENSING EVALUATOR SIGNATURE:

DATE: 08/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3
Control Number 56-AS-20231211135043
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/13/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/14/2024
Section Cited
CCR
80078(A)
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80078(a) Responsibility for Providing Care and Supervision

(a) The licensee shall provide care and supervision as necessary to meet the client's needs.
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The licensee has agreed to agreed to train all staff on the regulation cited above and will send LPA a copy of certification.
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Based on record, staff and client interviews
facility staff did not provided with care and supervision to C1, which poses an immediate health, safety or personal rights risk to persons in care.
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POC due date 8/14/2024.
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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.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Mary Rico
LICENSING EVALUATOR SIGNATURE:

DATE: 08/13/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3