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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 366426118
Report Date: 07/29/2026
Date Signed: 07/29/2026 12:28:40 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
04/29/2026 and conducted by Evaluator Paola Guerrero
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20260429095229
FACILITY NAME:FIRST STEP FONTANAFACILITY NUMBER:
366426118
ADMINISTRATOR:VISOR, MARYFACILITY TYPE:
775
ADDRESS:8621 JUNIPER AVE STE 101TELEPHONE:
(909) 428-6201
CITY:FONTANASTATE: CAZIP CODE:
92335
CAPACITY:60CENSUS: 52DATE:
07/29/2026
UNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Danielle EdwardsTIME COMPLETED:
12:30 PM
ALLEGATION(S):
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Lack of supervision resulting in resident sustaining second degree burn.
INVESTIGATION FINDINGS:
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 On 7/29/2026, Licensing Program Analyst (LPA) Paola Guerrero conducted an unannounced visit to the facility to deliver the investigative findings for the above allegation. LPA met with Program Manager Danielle Edwards and explained the purpose of the visit.

The investigation included interviews with the reporting party, facility staff, and other individuals with knowledge of the incident. LPA also reviewed the facility's incident report and other relevant documentation pertaining to the incident. It was alleged that Client 1 (C1) sustained second-degree burns due to lack of staff supervision. During the investigation, interviews with staff consistently revealed that Client 2 (C2) was observed carrying a bowl of hot soup without direct staff supervision. Staff acknowledged that C2 required supervision during meal service and should not have been permitted to independently carry hot food. Interviews further revealed that although staff were present in the dining area, they were not actively supervising clients at the time of the incident.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Paola Guerrero
LICENSING EVALUATOR SIGNATURE:

DATE: 07/29/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2026
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-20260429095229
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: FIRST STEP FONTANA
FACILITY NUMBER: 366426118
VISIT DATE: 07/29/2026
NARRATIVE
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 Interviews consistently established that while C2 was carrying the bowl of hot soup, C2 came into contact with C1, causing the hot soup to spill onto C1. As a result, C1 sustained second-degree burn injuries. Facility records reviewed by LPA were consistent with statements obtained during interviews regarding the circumstances of the incident and the injuries sustained by C1. Based on interviews and records reviewed, LPA determined that staff failed to provide adequate supervision during meal service. The preponderance of the evidence established that the lack of active supervision allowed C2 to independently carry hot food when staff acknowledged C2 should not have done so. This lack of supervision directly contributed to the incident in which C1 sustained second-degree burns. Based on the evidence obtained during the investigation, the allegation that facility staff failed to provide adequate supervision, resulting in C1 sustaining second-degree burns, is Substantiated. A finding that a complaint is substantiated means there is a preponderance of evidence to prove that the alleged violation occurred.

An exit interview was conducted with Program Manager Danielle Edwards. This report, appeal rights, and the attached LIC 9099-D were discussed and provided at the conclusion of the visit.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Paola Guerrero
LICENSING EVALUATOR SIGNATURE:

DATE: 07/29/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 56-AS-20260429095229
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: FIRST STEP FONTANA
FACILITY NUMBER: 366426118
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/29/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/30/2026
Section Cited
CCR
82078(a)
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Responsibility for Providing Care and Supervision 82078....(a) The licensee shall provide care and supervision necessary to meet the client's needs and all services specified in the admission agreement.

This requirement is not met as evidence by:
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The Licensee has agreed to read regulation: Responsibility for Providing Care and Supervision 82078 (a) and provide staff with training concerning supervision to meet every client’s needs and services according to the admission agreement. POC was cleared on the day of the visit. As facility already conducted training on 5/19/2026 Topic: Transporting Hot/Cold Liquids. As required by Inland Regional Center.
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Based on interviews, record review, the facility did not adhere by the regulation that is stated above and leaving Client 2 unsupervised with hot soup resulting in both clients C1 and C2, to sustain burns. C1 sustained second degree burns.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Efren Malagon
LICENSING EVALUATOR NAME: Paola Guerrero
LICENSING EVALUATOR SIGNATURE:

DATE: 07/29/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 3