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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 03:52:45 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
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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2
3
4
5
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7
8
9
Staff did not assist the client while using the restroom
Staff made an inappropriate comment towards a client
Staff intimidated a client while in care
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 allegations 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 allegation, Staff did not assist the client while using the restroom.

During staff interviews 5 out of the 5 staff stated they have not refused to assist C2 to use the bathroom. 5 out of the 5 stated that C2 can toilet themselves but they will still assist C2.

During client interviews, 2 out of the 3 clients stated they received assistance to the bathroom. 1 out of the 3 clients stated they’re independent.
Unsubstantiated
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 2
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 record review, C2 Physician Report 2023 and 2024 indicated they can care for their own toilet needs.

For the allegation, Staff made an inappropriate comment towards a client.

During staff interviews, 5 out of the 5 staff stated they have not made an inappropriate comment towards a client. During clients’ interviews, 3 out of the 3 clients stated no staff member has made an inappropriate comment towards them.

For the allegation, Staff intimidated a client while in care.

During staff interviews, 5 out of the 5 staff stated they have not intimidated a client while in care. During client interviews, 3 out of the 3 clients stated no staff has intimidated them.

Based on the evidence found during the investigation, the three (3) allegations 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 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: 2 of 2