<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 366426348
Report Date: 11/21/2024
Date Signed: 11/21/2024 01:38:08 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO ASC, 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
10/28/2024 and conducted by Evaluator Eldin Serrano
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20241028121007
FACILITY NAME:SAFEGUARD ADULT HOME IFACILITY NUMBER:
366426348
ADMINISTRATOR:BAYSINGER, ROYFACILITY TYPE:
735
ADDRESS:12779 2ND AVENUETELEPHONE:
(951) 544-2135
CITY:VICTORVILLESTATE: CAZIP CODE:
92395
CAPACITY:6CENSUS: 3DATE:
11/21/2024
UNANNOUNCEDTIME BEGAN:
11:50 AM
MET WITH:Roy Baysinger, AdministratorTIME COMPLETED:
01:40 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility is mismanaging resident's medication.
Facility is falsifying medication administration record.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 11/21/2024 at 11:50 AM, Licensing Program Analyst (LPA) Eldin Serrano arrived at the facility to investigate a complaint and deliver the findings for the above complaint allegation. Upon arrival, LPA met with Administrator Roy Baysinger, and LPA informed Administrator Baysinger of the purpose of the visit. The investigation consisted of file review, interviews as well as observation.
The investigation was conducted by LPA Serrano. The investigation consisted of records review and interviews with relevant parties. The allegations indicated that:
#1 Facility is mismanaging resident's medication.
#2 Facility is falsifying medication administration record.
LPA did not find evidence to corroborate the allegation.
*** Continuation in LIC9099C ***
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Eldin Serrano
LICENSING EVALUATOR SIGNATURE:

DATE: 11/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2024
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-20241028121007
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: SAFEGUARD ADULT HOME I
FACILITY NUMBER: 366426348
VISIT DATE: 11/21/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Interview with the Administrator Baysinger indicated that the facility submitted a Special Incident Report (SIR) to let Inland Regional Center of the discontinuation of the Omega 3 by Client #1 (C1). Furthermore, the administrator stated that there is no vitamin D that C1 is taking, and he let C1 to use his own personal omega 3 over the counter until the doctor instructed to discontinue the supplement due to cost concern.

Based on the evidence, the allegation that the facility is mismanaging resident's medication.
and the facility is falsifying medication administration record. are UNSUBSTANTIATED. A finding that the complaint is 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, therefore the allegation is unsubstantiated at this time.

An exit interview was conducted with this report, LIC9099 was discussed and provided to Administrator Roy Baysinger.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Eldin Serrano
LICENSING EVALUATOR SIGNATURE:

DATE: 11/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2