374601291-6-17-2022-18-AS-DMUN-CJF5UM-20220919201606

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374601291
Report Date: 06/17/2022
Date Signed: 06/17/2022 10:23:17 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, 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
06/08/2022 and conducted by Evaluator Stephanie Torres

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20220608140005

FACILITY NAME:	FOREST VIEW GUEST HOME		FACILITY NUMBER:	374601291
ADMINISTRATOR:	DILLARD-BENDER, CAREY M.		FACILITY TYPE:	740
ADDRESS:	1145 EVERGREEN LANE		TELEPHONE:	(760) 945-4779
CITY:	VISTA	STATE: CA	ZIP CODE:	92084
CAPACITY:	6	CENSUS: 4	DATE:	06/17/2022
		UNANNOUNCED	TIME BEGAN:	08:52 AM
MET WITH:	Carey Dillard-Bender, Licensee		TIME COMPLETED:	10:30 AM

ALLEGATION(S):

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Facility not providing healthful conditions for residents

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA), Stephanie Torres, conducted an unannounced visit to the facility to initiate the investigation into the above allegation. The LPA met with Carey Dillard-Bender, Licensee, and informed her of the purpose of her visit.
On this visit the LPA conducted staff/resident interviews and toured the facility. Regarding the allegation, "Facility not providing healthful conditions for residents," it was alleged the facility is burning trash approximately four times a day. The tour revealed two fireplaces located on the premises, both of which were inspected. One fireplace was not being utilized, as it was covered with plywood and the second did not have remnants of trash at time of visit. Resident interviews reported no knowledge of the use of the fireplaces at the facility. Licensee Dillard-Bender stated trash is not being burned at any areas of the facility. In addition, the LPA observed trash cans on the premises and copies of a trash bill was provided. Therefore, this allegation is deemed UNSUBSTANTIATED at this time. A finding that the complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove the alleged violation occurred. This report was reviewed with the Licensee and a copy was provided.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Deborah Mullen	TELEPHONE: (951) 248-0313
LICENSING EVALUATOR NAME: Stephanie Torres	TELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:	DATE: 06/17/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2022

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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