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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 366426354
Report Date: 10/18/2024
Date Signed: 10/18/2024 02:00:39 PM

Unsubstantiated


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
09/05/2024 and conducted by Evaluator Paola Guerrero
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20240905113538
FACILITY NAME:XAVIER FAMILY HOMEFACILITY NUMBER:
366426354
ADMINISTRATOR:CARDEN, LORIFACILITY TYPE:
735
ADDRESS:9255 PALM LANETELEPHONE:
(909) 574-8129
CITY:FONTANASTATE: CAZIP CODE:
92335
CAPACITY:6CENSUS: 5DATE:
10/18/2024
UNANNOUNCEDTIME BEGAN:
12:36 PM
MET WITH:Mae TillettTIME COMPLETED:
02:10 PM
ALLEGATION(S):
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Staff did not provide adequate supervision to a client in care.
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Paola Guerrero and Beena Singh conducted an unannounced visit to deliver findings on the allegations listed above. LPAs met with Facility Caregiver Mae Tillett and explained the purpose of the visit. The investigation consisted of interviews and review of records.

First allegation, Staff did not provide adequate supervision to a client in care. Regarding the first allegation “Staff did not provide adequate supervision to a client in care” LPA conducted interviews with Staff during the interviews Staff #2 informed LPA that Staff #1 last day working at the facility was on 8/23/2024 and Staff #1 was no longer providing care or supervision to clients on the alleged date of (08/30/24), that was claimed. LPA reviewed documentation from Inland Regional Center requesting for Staff #1 to be removed. LPA observed that on 8/26/2024, Administrator informed Inland Regional Center that Staff #1 had been removed from all rosters.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Paola Guerrero
LICENSING EVALUATOR SIGNATURE:

DATE: 10/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2024
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-20240905113538
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: XAVIER FAMILY HOME
FACILITY NUMBER: 366426354
VISIT DATE: 10/18/2024
NARRATIVE
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LPA conducted an interview with Client#1 regarding the alleged allegation C#1 informed LPA that client was not sure that if the alleged allegation was a lie or the truth. Client #1 informed LPA that client does not remember and does not remember if other clients were around during the time of the incident. Due to the lack of evidence LPA has determined that the alleged allegation is Unsubstantiated.

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 Facility Caregiver Mae Tillett at the end of the visit.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Paola Guerrero
LICENSING EVALUATOR SIGNATURE:

DATE: 10/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2