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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 366426418
Report Date: 04/05/2023
Date Signed: 05/24/2023 10:11:04 AM

Unfounded


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
, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/03/2023 and conducted by Evaluator Rayshaun Nickolas
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20230403100950
FACILITY NAME:M&M BOARD & CAREFACILITY NUMBER:
366426418
ADMINISTRATOR:MERCADO, VICTORFACILITY TYPE:
740
ADDRESS:18245 CHERRY ST.TELEPHONE:
(760) 488-1698
CITY:HESPERIASTATE: CAZIP CODE:
92345
CAPACITY:8CENSUS: 3DATE:
04/05/2023
UNANNOUNCEDTIME BEGAN:
11:42 AM
MET WITH:Victor Mercado, LicenseeTIME COMPLETED:
12:27 PM
ALLEGATION(S):
1
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9
Facility staff did not follow reporting requirements.
INVESTIGATION FINDINGS:
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9
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13
Licensing Program Analyst (LPA) Rayshaun Nickolas visited the facility unannounced to deliver the finding on the above allegation. LPA met with Victor Mercado and explained the purpose of the visit. The investigation consisted of file reviews and interviews with relevant parties.

The allegation alleged that resident # 1 (R1) fell in the community on March 29, 2023. The allegation alleged that both the administrator and R1 stated that R1 received medical treatment for the fall; however, the administrator failed to report the incident to Community Care Licensing Division (CCLD) and other agencies. Title 22 of the California Code of Regulations (CCR), Section 87211 Reporting Requirements (a)(1) states, “A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven (7) days of the occurrence…”. The Licensee did not violate regulation because CCLD received this allegation from the reporting party (RP) on April 3, 2023, five (5) days after the incident. The Licensee had until April 5, 2023, to report the incident.


Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Rayshaun NickolasTELEPHONE: 951-255-9516
LICENSING EVALUATOR SIGNATURE:

DATE: 04/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/05/2023
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-20230403100950
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
, CA 92507
FACILITY NAME: M&M BOARD & CARE
FACILITY NUMBER: 366426418
VISIT DATE: 04/05/2023
NARRATIVE
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This agency has investigated the complaint allegations. We have found that the complaint was unfounded meaning that the allegations were false, could not have happened and/or are without a reasonable basis. We have therefore dismissed the complaint.
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Rayshaun NickolasTELEPHONE: 951-255-9516
LICENSING EVALUATOR SIGNATURE:

DATE: 04/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/05/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2