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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374600027
Report Date: 03/20/2023
Date Signed: 03/20/2023 10:13:51 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, 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
03/01/2023 and conducted by Evaluator Amy Domingo
COMPLAINT CONTROL NUMBER: 08-AS-20230301150606
FACILITY NAME:FAMILY VALUES ADULT RESIDENTIAL FACILITYFACILITY NUMBER:
374600027
ADMINISTRATOR:REGINA AGUILO UYFACILITY TYPE:
735
ADDRESS:8509 DALLAS STREETTELEPHONE:
(619) 697-4685
CITY:LA MESASTATE: CAZIP CODE:
91942
CAPACITY:4CENSUS: 4DATE:
03/20/2023
UNANNOUNCEDTIME BEGAN:
01:28 PM
MET WITH:Regina Uy, LicenseeTIME COMPLETED:
02:29 PM
ALLEGATION(S):
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Staff did not maintain complete medication records
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Amy Domingo, conducted an unannounced visit to deliver findings to the above mentioned complaint allegation. LPA Domingo identified herself and discussed the purpose of the visit with Administrator Regina Uy.

The Department’s investigation consisted of client and outside sources records review, interviews with staff and outside sources.

It was alleged that the staff did not maintain complete medication records. It was reported that Client #1 (C1) and Client #2 (C2) (See LIC811 confidential names list) were prescribed a pro re nata (PRN) “as needed” medication. Based on the review of client records, each PRN dose was maintained in the client's records. The records included the date and time the PRN medication was taken, the dosage taken, and the client's response. Based on records reviewed the Licensee has the needed documentation.
(Continued on LIC9099C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: John Rante
LICENSING EVALUATOR NAME: Amy Domingo
LICENSING EVALUATOR SIGNATURE:

DATE: 03/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2023
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 08-AS-20230301150606
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: FAMILY VALUES ADULT RESIDENTIAL FACILITY
FACILITY NUMBER: 374600027
VISIT DATE: 03/20/2023
NARRATIVE
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The Department has investigated the above mentioned allegation and the preponderance of the evidence standard has not been met. Therefore, the allegation is unsubstantiated.

A copy of this report along with Licensee Appeal Rights (LIC 9058 03/22) was provided to the Licensee and the signature on this form confirms receipt of these rights.
SUPERVISORS NAME: John Rante
LICENSING EVALUATOR NAME: Amy Domingo
LICENSING EVALUATOR SIGNATURE:

DATE: 03/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2