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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 366425780
Report Date: 08/15/2023
Date Signed: 08/15/2023 09:08:12 AM

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
, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/12/2022 and conducted by Evaluator Rayshaun Nickolas
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20221212170731
FACILITY NAME:SPECIALIZED RESIDENTIAL LUPINEFACILITY NUMBER:
366425780
ADMINISTRATOR:LAWANNA JONESFACILITY TYPE:
735
ADDRESS:22334 LUPINE RDTELEPHONE:
(760) 247-2391
CITY:APPLE VALLEYSTATE: CAZIP CODE:
92308
CAPACITY:4CENSUS: DATE:
08/15/2023
UNANNOUNCEDTIME BEGAN:
08:58 AM
MET WITH:LaWanna Jones, AdministratorTIME COMPLETED:
09:07 AM
ALLEGATION(S):
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Neglect/lack of supervision resulting in client injury.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Rayshaun Nickolas met with LaWanna Jones, Administrator in the Riverside/San Bernardino Regional Office to deliver findings on the above allegation. The investigation included file reviews, a tour of the facility, and interviews with relevant parties.

The allegation alleged that the reporting party (RP) observed a significant sized knot and laceration above resident #1’s (R1’s) right eye. The allegation alleged that the incident occurred during the overnight shift, with no explanation by staff #1 (S1) working that shift about what happened. LPA Nickolas' interview with S1 revealed that S1 denied injuring R1, but R1 started throwing things in their room. LPA Nickolas' interview with R1 revealed that R1 could not communicate what happened to them and why they had injuries above their right eye. LPA Nickolas' interview with resident #2 (R2) revealed that they overheard various noises, including S1 asking R1 to calm down and R1's screaming. However, R2 remained in their room and did not observe anything.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Rayshaun Nickolas
LICENSING EVALUATOR SIGNATURE:

DATE: 08/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2023
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-20221212170731
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
, CA 92507
FACILITY NAME: SPECIALIZED RESIDENTIAL LUPINE
FACILITY NUMBER: 366425780
VISIT DATE: 08/15/2023
NARRATIVE
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LPA Nickolas' interviews with three (3) other facility staff members revealed that they did not witness the incident but observed the injuries to R1's right eye later that day. The finding is Unsubstantiated. There is no evidence or witnesses to corroborate the allegation.

A finding of Unsubstantiated means 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 and copy of this report was provided.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Rayshaun Nickolas
LICENSING EVALUATOR SIGNATURE:

DATE: 08/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2