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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 366424311
Report Date: 12/26/2024
Date Signed: 12/26/2024 02:04:38 PM

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
10/28/2024 and conducted by Evaluator Becky Mann
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20241028162309
FACILITY NAME:KAISER SPECIALIZED RESIDENTIAL MERLOTFACILITY NUMBER:
366424311
ADMINISTRATOR:ANAHI MURILLOFACILITY TYPE:
735
ADDRESS:21295 MERLOT LNTELEPHONE:
(760) 240-9976
CITY:APPLE VALLEYSTATE: CAZIP CODE:
92307
CAPACITY:4CENSUS: 3DATE:
12/26/2024
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Dontee Weaver, AdministratorTIME COMPLETED:
02:10 PM
ALLEGATION(S):
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Staff do not ensure that resident is provided with hygiene products while in care.
Staff do not allow resident to possess and control their own cash resources while in care.
Staff threaten resident in care.
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 Mann met with Dontee Weaver, Administrator and explained the purpose of today's visit. The investigation consisted of LPA observations, record reviews, interviews with staff and residents.

The allegation that staff do not ensure that resident is provided with hygiene products while in care. The 3 out of 3 residents stated that staff do ensure that resident is provided with hygiene products while in care. LPA observed the hygiene supply at the facility and found that there was an adequate amount of hygiene supply available for residents in care. The six (6) staff and one (1) outside party interviewed stated that staff do ensure that resident is provided with hygiene products while in care.


Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Becky Mann
LICENSING EVALUATOR SIGNATURE:

DATE: 12/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/26/2024
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-20241028162309
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: 12/26/2024
NARRATIVE
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The allegation that staff do not allow resident to possess and control their own cash resources while in care. The 3 out of 3 residents stated that staff do allow resident to possess and control their own resources while in care. The 6 staff and 1 outside party stated that they allow resident to possess and control their own resources while in care.

The allegation that staff threaten resident in care. The 3 out of 3 residents stated that staff does not threaten resident in care. The 6 staff and 1 outside party stated that they have not threatened resident in care.

Based on evidence obtained during the investigation, the above allegations are 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 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: 12/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/26/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2