366426126-2-23-2022-18-AS-EMAN-CDPSEF-20220421134838

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 366426126
Report Date: 02/23/2022
Date Signed: 02/23/2022 03:24:16 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
02/17/2022 and conducted by Evaluator Stephanie Williams

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20220217140913

FACILITY NAME:	CRYSTAL GARDEN RCFE		FACILITY NUMBER:	366426126
ADMINISTRATOR:	EBADPOUR, KAMAL		FACILITY TYPE:	740
ADDRESS:	13224 IROQUOIS		TELEPHONE:	(760) 503-9180
CITY:	APPLE VALLEY	STATE: CA	ZIP CODE:	92308
CAPACITY:	8	CENSUS: 5	DATE:	02/23/2022
		UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:			TIME COMPLETED:	03:40 PM

ALLEGATION(S):

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Staff physically abusing a resident
Staff is having inappropriate interactions with a resident
Staff is mishandling medications
Staff was intoxicated while providing care
Uncleared adult providing care to residents
Staff threatens resident

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Stephanie Williams made an unannounced visit to the facility in order to deliver findings for the above allegations. LPA Williams identified herself to Staff Member, Breeana Redwine, who was also informed of the purpose of the visit. LPA Williams spoke with Administrator, Kamal Ebadpour, over the phone. The investigation consisted of direct observations, records review, and interviews with staff and residents.

In regards to allegation #1, LPA Williams interviewed Staff #1 (S1) who denied witnessing or having knowledge of Staff #2 (S2) physically abusing Resident #1 (R1). LPA Williams interviewed S2 who denied physically abusing R1. LPA Williams interviewed Staff #3 (S3) who also denied witnessing or having knowledge of S2 physically abusing the residents. S1 also stated that they have reviewed the facility's cameras and has not seen any abuse. LPA Williams interviewed R1, Resident #2 (R2), and Resident #3 (R3) who all denied that any staff members are physically abusing them.

In regards to allegation #2, LPA Williams interviewed S1, S2, and S3, who all denied that staff members

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 248-0337
LICENSING EVALUATOR NAME: Stephanie Williams	TELEPHONE: (951) 248-0317
LICENSING EVALUATOR SIGNATURE:	DATE: 02/23/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2022

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-20220217140913

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: CRYSTAL GARDEN RCFE	FACILITY NUMBER: 366426126
	VISIT DATE: 02/23/2022

NARRATIVE

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are having inappropriate interactions with residents. LPA Williams was unable to interview Staff #4 (S4) to retrieve a statement. LPA Williams interviewed R1, R2, and R3, who all denied staff members were having inappropriate reactions with them.

In regards to allegation #3, LPA Williams interviewed S1, S2, and S3, who all denied that residents are being chemically restrained and their medications are being dispensed inappropriately. S2 stated that medications are dispensed appropriately within physician's orders and medications are only handled by trained staff. S2 denied that R1's medications were given to R2 in order to chemically restrain R2. LPA Williams interviewed R1, R2, and R3, who all denied that staff members are mishandling medications. R1 and R2 both denied feeling unreasonably lethargic or sleepy due to over-medication. LPA Williams reviewed the Medication Administration Record (MAR) in which it appeared medications were dispensed appropriately.

In regards to allegation #4, LPA Williams interviewed S2 who denied being intoxicated while providing care to the residents. S2 stated that they once had a beverage in a can which looked similar to that of an alcoholic beverage; however, S2 adamantly stated that the beverage was non-alcoholic. LPA Williams interviewed S1 and S3 who denied witnessing S1 providing care to residents while intoxicated.

In regards to allegation #5, LPA Williams interviewed S1 who stated that Staff #4 (S4) was not employed by the facility at anytime. S1 stated that they told S4 that they were unable to work for the facility as S4's background clearance had not been approved. S1 stated that S4 did not work at the facility nor provided care for the residents. LPA Williams interviewed S2 and S3 who also stated that S4 did not provide care to residents in the facility and was let go upon learning S4's background clearance denial.

In regards to allegation #6, LPA Williams interviewed S1, S2, and S3, who all denied threatening the residents nor have they witnessed other staff members threatening the residents. LPA Williams interviewed R1, R2, and R3, who all denied that staff members have threatened them.

Based on evidence 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 (LIC 9099) was discussed and a copy was provided to the facility representative.

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 248-0337
LICENSING EVALUATOR NAME: Stephanie Williams	TELEPHONE: (951) 248-0317
LICENSING EVALUATOR SIGNATURE:	DATE: 02/23/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2022

LIC9099 (FAS) - (06/04)

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