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

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 366426354
Report Date: 10/14/2025
Date Signed: 10/14/2025 03:40:40 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,
, CA
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/08/2021 and conducted by Evaluator Yolanda Delgado
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20210708101517
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:
10/14/2025
UNANNOUNCEDTIME BEGAN:
03:25 PM
MET WITH:Chyna Lee, DSPTIME COMPLETED:
03:50 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Resident had unexplained bruise on arm
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst, (LPA) Yolanda Delgado arrived unannounced at the facility to conclude an investigation pertaining to the allegation listed above. LPA met with Chyna Lee, DSP and explained the purpose of the visit.

On July 8, 2021, Community Care Licensing received a complaint alleging a resident had an unexplained bruise on their arm and that when resident was asked what happened resident stated it was a long story and resident looked depressed. LPA conducted interview with Administrator which revealed that R1 is very active, has self-injury behaviors and can be aggressive at times. Interview with R1 revealed that R1 does bruise easily and denied that any staff have caused harm to sustain bruising. Information obtained from interviews with residents revealed that R1 has tumbled and fallen at times where R1 has gotten bruises.

(Continued on Page 2)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Yolanda Delgado
LICENSING EVALUATOR SIGNATURE:

DATE: 10/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2025
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 18-AS-20210708101517
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
FACILITY NAME: XAVIER FAMILY HOME
FACILITY NUMBER: 366426354
VISIT DATE: 10/14/2025
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
(Continued from Page 1)

R1’s IPP dated July 9, 2021, was reviewed and states “that R1 will have behavior to destroy property when R1 becomes really upset and throw whatever items is in R1’s hand, during the outbursts that occur less than once a week, R1 may require staff intervention. R1 has exhibited physical aggression (slapping/pushing) towards others less than once a month. When R1 becomes frustrated, R1 may display self-injury in the form of banging head against the wall/hard surface. R1 has a history of puncturing/cutting wrist as an attention seeking behavior, specifically to get 5150’d.” According to the facility notes entry dated July 4, 2021, R1 had physical altercation with another resident and staff intervened to de-escalate were R1 was hitting the staff and R1 was kicking, hitting head on the ground and swinging at staff.

Based on interviews and facility records, the allegation that resident had unexplained bruise on arm is unsubstantiated. Although the allegations may have happened or are valid, there is no preponderance of evidence to prove the alleged violations did or did not occur.

An exit interview was conducted with Chyna Lee and a copy of this report along with LIC811- Confidential Names list was provided.
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Yolanda Delgado
LICENSING EVALUATOR SIGNATURE:

DATE: 10/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2