366427383-5-15-2025-56-AS-NBRN-DLZPDJ-20250930111338

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 366427383
Report Date: 05/15/2025
Date Signed: 05/15/2025 01:41:54 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
05/09/2025 and conducted by Evaluator Lavette Farlow

COMPLAINT CONTROL NUMBER: 56-AS-20250509121424

FACILITY NAME:	ESPINOZA ADULT CARE HOME I		FACILITY NUMBER:	366427383
ADMINISTRATOR:	LYDIA ESCUTIA		FACILITY TYPE:	735
ADDRESS:	14232 SAVANA STREET		TELEPHONE:	(909) 770-3544
CITY:	ADELANTO	STATE: CA	ZIP CODE:	92301
CAPACITY:	5	CENSUS: 4	DATE:	05/15/2025
		UNANNOUNCED	TIME BEGAN:	10:20 AM
MET WITH:	Amber Espinoza Licensee, and Rae Espinoza Administrator		TIME COMPLETED:	01:45 PM

ALLEGATION(S):

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Licensee does not ensure that residents are provided with food that is of good quality. Licensee does not ensure that the facility has an adequate supply of food.
Staff do not follow proper food safety protocols.
Staff falsify incident reports.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) LaVette Farrow and Edith Conchas conducted an unannounced visit to the facility to investigation a complaint of the of above mentioned allegations. LPAs met with house manager Bessie Ozenbaugh who provided a tour of facility and Amber Espinoza and Rae Espinoza were called and informed of the reason for today's visit. The investigation consisted of interviews with staff, and review of records.

Allegation 1: It is alleged that Licensee does not ensure that residents are provided with food that is of good quality. Based on LPA's interviews and observation during the LPA's facility tour. LPA's observed the facility has no expired perishable and nonperishable items in facility.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Lavette Farlow
LICENSING EVALUATOR SIGNATURE:	DATE: 05/15/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2025

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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Control Number 56-AS-20250509121424

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: ESPINOZA ADULT CARE HOME I	FACILITY NUMBER: 366427383
	VISIT DATE: 05/15/2025

NARRATIVE

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The facility has sufficient food supply in the refrigerator, pantry, and storage for the residents in care for 7 days of nonperishable and 2 days of perishable items. Also, the facility maintains a weekly meal plan that was current and posted on the refrigerator. Based on the findings the allegation is UNSUBSTANTIATED.

Allegation 2 Licensee does not ensure that the facility has an adequate supply of food. LPA's observation during the tour there was adequate food supply in the refrigerator, deep freezer, pantry, and extra storage for the resident in care of 7 days of nonperishable and 2 days of perishable items. Based on the findings the allegation is UNSUBSTANTIATED.

Allegation 3 Staff do not follow proper food safety protocols. LPA's observed staff preparing lunch meals and washing hands, using gloves and labeling items along with dates. Based on LPA's observation the above findings is UNSUBSTANTIATED.

Allegation 4 Staff falsify incident reports. The LPA's interviewed and observed SIR in the facility files that have been reported. LPA's interviewed 7 out of 7 staff. 7 out of 7 staff revealed they inform S1 of any incidents and documents in clients files or daily care notes. The licensee completes all SIR and sends them to CCLD. Based on LPA's interviews and observations, the above findings is UNSUBSTANTIATED.

Based on the information above, the allegations is unsubstantiated. A finding of UNSUBSTANTIATED means although the allegation may have happened or is 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 LIC 9099 and LIC 9099C was discussed and a copy was provided to the Licensee Amber Espinoza and Administrator Rae Espinoza.

SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Lavette Farlow
LICENSING EVALUATOR SIGNATURE:	DATE: 05/15/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2025

LIC9099 (FAS) - (06/04)

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