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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 366424311
Report Date: 05/16/2025
Date Signed: 05/16/2025 01:11:55 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
08/09/2023 and conducted by Evaluator Mary Rico
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20230809172810
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:
05/16/2025
UNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Administrator - Tranell MartinTIME COMPLETED:
01:20 PM
ALLEGATION(S):
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Facility staff did not ensure that resident was properly clothed.
Facility staff left a resident on the floor.
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Mary Rico and Antoinette Davis conducted an unannounced visit to deliver findings on the allegations listed above. LPA met with District Manager Tranell Martin and explained the purpose of the visit. The investigation consisted of staff interviews and document review.

For the allegation, Facility staff took photo of resident without any undergarments.

The investigation was conducted by deparment staff which consisted of interviews and review of records. Department staff conducted five (5) staff interviews. Four (4) out of the five (5) staff confirmed S1 took a photo of R1 not properly clothed from the waist down and had shown staff members. In addition, S1 admitted they took a photo of R1 not properly clothed from the waist down and admitted sending the photo to S2. Furthermore, S2 provided the photo to Department staff.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Mary Rico
LICENSING EVALUATOR SIGNATURE:

DATE: 05/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2025
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 3
Control Number 56-AS-20230809172810
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: 05/16/2025
NARRATIVE
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For the allegation, Facility staff left a resident on the floor.

Department staff conducted five (5) staff interviews. Three (3) out of the five (5) staff confirmed facility staff left R1 on the floor without undergarment. Department staff received R1 photo that shows resident was left on the floor.

Based on the evidence gathered during the investigation, the two (2) allegations listed above are deemed SUBSTANTIATED. A finding that the complaints are SUBSTANTIATED means that the allegations are valid because the preponderance of evidence the standard has been met.

During today’s visit, two (2) deficiencies 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 District Manager Tranell Martin, along with a copy of the appeal rights.

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

DATE: 05/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 56-AS-20230809172810
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: 05/16/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/19/2025
Section Cited
CCR
80072(a)(3)
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80072(a)(3)Personal Rights (a)(3)
(3)To be free from corporal or unusual punishment, infliction of pain, humiliation, .. functions, including eating, sleeping, or toileting;.. medication or aids to physical functioning.This requirement is not met as evidenced by:
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Administrator has agreed to read over the entire Personal Rights regulation and provide training to all staff regarding 80072(a)(3). Administrator will provide proof to LPA Rico that all staff members received training.
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Based on interviews and document review, the Licensee did not comply with the section cited above evidenced by S1 taking a picture of R1 not properly clothed from the waist below which poses an immediate health, safety, or personal rights risk to persons in care.
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POC due date by 5/19/2025
Type A
05/19/2025
Section Cited
CCR
80065(a)
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 80065(a)Personnel Requirements
(a) Facility personnel shall be competent to provide the services necessary to meet individual client needs and shall, at all times, be employed in numbers necessary to meet such needs.This requirement is not met as evidenced by:
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Administrator has agreed to read over the entire Personal Rights regulation and provide training to all staff regarding 80065(a). Administrator will provide proof to LPA Rico that all staff members received training.
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Based on interviews and document review, the Licensee did not comply with the section cited above evidenced by facility staff leaving R1 on the floor without undergarment which poses an immediate health, safety, or personal rights risk to persons in care.
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POC due date 5/19/2025
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: 05/16/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3