366424489-10-28-2021-18-AS-EMAN-CDNV3Y-20220420160531

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 366424489
Report Date: 10/28/2021
Date Signed: 10/28/2021 02:49:29 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
10/26/2021 and conducted by Evaluator Stephanie Williams

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20211026090504

FACILITY NAME:	KAISER SPECIALIZED RESIDENTIAL PERIGNON		FACILITY NUMBER:	366424489
ADMINISTRATOR:	JOYNER, NICOLE		FACILITY TYPE:	735
ADDRESS:	13263 PERIGNON PL		TELEPHONE:	(909) 217-9635
CITY:	APPLE VALLEY	STATE: CA	ZIP CODE:	92308
CAPACITY:	4	CENSUS: 4	DATE:	10/28/2021
		UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Wilton Miles		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Staff yelled at resident
Facility does not have a meal menu available
Residents are not getting their needs met

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Stephanie Williams made an unannounced visit to the property in order to initiate a complaint investigation into the above allegations. The LPA identified herself to Administrator, Wilton Miles, and discussed the purpose of the visit with Miles. The investigation consisted of records review, direct observation, and interviews with the Administrator and clients.

In regards to allegation #1, LPA interviewed Client #1 (C1) who denied that facility staff are yelling or speaking inappropriately to clients. LPA interviewed Staff #1 (S1), Staff #2 (S2), Staff #3 (S3), who denied witnessing or having knowledge of facility staff yelling or speaking inappropriately to the clients. S1, S2, and S3 all stated that they may be firm and speak loudly to the clients due to behavioral episodes or because some clients are nonverbal.

In regards to allegation #2, LPA observed that the facility had several meal menus including a menu for the current week. LPA interviewed S1, S2, and S3 who stated that facility staff has a Dietitian who creates the

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Stephanie Williams
LICENSING EVALUATOR SIGNATURE:	DATE: 10/28/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 18-AS-20211026090504

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: KAISER SPECIALIZED RESIDENTIAL PERIGNON	FACILITY NUMBER: 366424489
	VISIT DATE: 10/28/2021

NARRATIVE

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meal menu and provides the menu to staff as appropriate.

In regards to allegation #3, LPA interviewed C1 who stated that staff are "good" and believes that staff members have been attentive in meeting the clients needs. S1, S2, and S3 all stated that residents needs are being met. LPA observed that the staff members appear to be attentive to the clients at the time of visit.

Based on evidence/record review/ interviews obtained during today’s visit, LPA has determined that the above allegation 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 was provided to Miles at the conclusion of the investigation.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Stephanie Williams
LICENSING EVALUATOR SIGNATURE:	DATE: 10/28/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2021

LIC9099 (FAS) - (06/04)

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