366427078-10-12-2022-56-AS-EMAN-CKCMZP-20221019100324

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 366427078
Report Date: 10/10/2022
Date Signed: 10/12/2022 03:19:58 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
, CA 92507

This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/29/2022 and conducted by Evaluator Anna Bueno

PUBLIC

COMPLAINT CONTROL NUMBER: 56-AS-20220829161750

FACILITY NAME:	HOLLY LAND CARE HOME		FACILITY NUMBER:	366427078
ADMINISTRATOR:	PENDING		FACILITY TYPE:	735
ADDRESS:	2044 HOLLY AVENUE		TELEPHONE:	(909) 972-8497
CITY:	ONTARIO	STATE: CA	ZIP CODE:	91762
CAPACITY:	6	CENSUS: 4	DATE:	10/10/2022
		UNANNOUNCED	TIME BEGAN:	02:18 PM
MET WITH:	Sigmon Manalo, DSP		TIME COMPLETED:	02:49 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff member physically abuses residents.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Anna Bueno conducted an unannounced visit to the facility to deliver findings on the above allegation. LPA identified herself to DSP Sigmond Manalo who was notified of the reason for today’s visit. The investigation included records review, LPA observations, and staff, client, and witness interviews.

The allegation is Staff member physically abuses residents. Client 1 (C1) alleges that Staff 1 (S1) hits Client 2 (C2) and Client 3 (C3). Records reviewed show that C1 and C2 have documented histories of making false statements. Staff interviews deny hitting and/or witnessing another staff hit any clients. Client interview reveal that staff do not hit client. LPA observed client making verbal threats to each other but responded to staff verbal redirection. Based on the available information, we have found the complaint allegation to be UNSUBSTANTIATED.

A finding of unsubstantiated means that although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. An exit interview was conducted where this report was discussed with, and a copy was provided to Mr. Manalo at the conclusion of the visit.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Anna Bueno
LICENSING EVALUATOR SIGNATURE:	DATE: 10/10/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2022

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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