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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 370808597
Report Date: 08/25/2022
Date Signed: 08/25/2022 11:04:59 AM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/12/2022 and conducted by Evaluator Esther Miller
PUBLIC
COMPLAINT CONTROL NUMBER: 08-AS-20220412112724
FACILITY NAME:STONE MOUNTAIN RANCHFACILITY NUMBER:
370808597
ADMINISTRATOR:ROBINSON, DEZIFACILITY TYPE:
735
ADDRESS:16585 HIGHLAND VALLEY ROADTELEPHONE:
(760) 789-4600
CITY:RAMONASTATE: CAZIP CODE:
92065
CAPACITY:15CENSUS: 13DATE:
08/25/2022
UNANNOUNCEDTIME BEGAN:
09:12 AM
MET WITH:Glen Smith, Case ManagerTIME COMPLETED:
09:45 AM
ALLEGATION(S):
1
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9
Incident involving client was not reported to their responsible party.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Esther Miller conducted an unannounced complaint investigation visit to the facility in order to deliver findings on the above allegation. LPA was granted entry to the facility by Glen Smith, Case Manager, after identifying herself and explaining the reason for the visit.

On April 12, 2022, it was alleged that the facility did not report an incident that required medical treatment to the client’s responsible party. The Department’s investigation consisted of review of facility records, outside source records, and interviews of facility staff and outside sources.

[Continued on LIC9099-C, Page 1 of 2]
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Esther Miller
LICENSING EVALUATOR SIGNATURE:

DATE: 08/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2022
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 08-AS-20220412112724
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: STONE MOUNTAIN RANCH
FACILITY NUMBER: 370808597
VISIT DATE: 08/25/2022
NARRATIVE
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[Continued from LIC9099, page 2 of 2]

On April 12, 2022, the facility self-reported a fall involving Client 1 (C1) to Community Care Licensing. C1 was taken to Palomar Medical Center Poway Emergency Room around 7PM on April 11, 2022 after the accidental fall. Facility records indicated that C1 returned to the facility around 11PM, after receiving medical care for injuries related to the fall. At 10:26AM on April 12, 2022, the day after the fall, facility records and outside source records revealed that an email from the facility was sent to C1’s responsible party informing them of C1’s medical treatment. Outside source records revealed that numerous emails and pictures were sent between the responsible party and the facility concerning C1’s care after the fall. The facility’s emails to the responsible party included C1’s status, pictures, updates, and activities. Requests for photos and communication by the responsible party were provided and replied to by the facility as evidenced by the twenty-three (23) emails exchanged on April 12, 2022.

Based on the evidence obtained during the complaint investigation, the allegation that the licensee did not keep a responsible party informed of a client’s care is found to be UNSUBSTANTIATED, meaning that although the allegation may have happened or may be valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted with Case Manager; a copy of this report and Licensee's Rights (LIC9058) were provided to Case Manager.
SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Esther Miller
LICENSING EVALUATOR SIGNATURE:

DATE: 08/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2