374603896-5-30-2024-08-AS-JLOT-D7Q3RF-20240731182841

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374603896
Report Date: 05/30/2024
Date Signed: 05/30/2024 01:30:44 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 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
05/21/2024 and conducted by Evaluator Liliana Silveira

COMPLAINT CONTROL NUMBER: 08-AS-20240521114619

FACILITY NAME:	RUSSELL HOMES MANOR		FACILITY NUMBER:	374603896
ADMINISTRATOR:	WAINSCOTT, ANGELIA		FACILITY TYPE:	735
ADDRESS:	1146 SUMNER AVE		TELEPHONE:	(619) 749-0704
CITY:	EL CAJON	STATE: CA	ZIP CODE:	92021
CAPACITY:	6	CENSUS: 5	DATE:	05/30/2024
		UNANNOUNCED	TIME BEGAN:	10:15 AM
MET WITH:	Program Director Shontel Grivno		TIME COMPLETED:	01:45 PM

ALLEGATION(S):

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Licensee did not have a food menu.
Licensee did not maintain a fire drill log.
Licensee did not maintain backyard.
P&I form was not completed accordingly.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Liliana Silveira conducted an unannounced complaint visit to conduct an investigation on the above mentioned allegations. LPA spoke with Program Director (PD) Shontel Grivno and was granted entry into the facility. PD Grivno was advised of the complaint visit’s purpose. House Manager Joseph Baker arrived shortly after.

The investigation consisted of LPA observations and a facility records review. It also involved a brief facility tour and an interview with the Program Director and House Manager.

It was alleged that the Licensee did not have a food menu. A records review revealed that the facility has a binder with a 12 week supply of rotating food menus and recipes. It was also alleged that the Licensee did not maintain a fire drill log. A records review revealed that the facility maintains a fire drill log and the last fire drill was conducted in April 2024. (Continued on LIC 9099-C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Jennifer Lott
LICENSING EVALUATOR NAME: Liliana Silveira
LICENSING EVALUATOR SIGNATURE:	DATE: 05/30/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2024

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 08-AS-20240521114619

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: RUSSELL HOMES MANOR	FACILITY NUMBER: 374603896
	VISIT DATE: 05/30/2024

NARRATIVE

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(CONTINUED FROM LIC 9099)

It was also alleged that the Licensee’s Cash and Resources Information forms for the clients were not completed accordingly. LPA reviewed the Cash and Resource records for all five (5) clients currently living at the facility. LPA observed that the forms contained the required documentation, and the money present matched the amounts documented on the forms. Lastly, it was alleged that the Licensee did not maintain the backyard. LPA toured the backyard. During the LPA’s investigation, the facility maintenance worker immediately fixed a wobbly fence and removed some broken drawers that were present. LPA observed that the backyard was clean and maintained.

The allegations that the Licensee did not have a food menu, the Licensee did not maintain a fire drill log, the Licensee did not maintain the backyard and that the Cash and Resource Information forms were not completed accordingly are unsubstantiated. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations occurred, therefore the allegations are unsubstantiated.

LPA Silveira conducted an exit interview with Shontel. A copy of the Complaint Investigation Report (LIC9099) and Licensee Rights (LIC9058 03/22) were provided. The signature on this report acknowledges receipt of the reports.

SUPERVISORS NAME: Jennifer Lott
LICENSING EVALUATOR NAME: Liliana Silveira
LICENSING EVALUATOR SIGNATURE:	DATE: 05/30/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2024

LIC9099 (FAS) - (06/04)

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