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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374604699
Report Date: 06/05/2024
Date Signed: 06/05/2024 03:26:06 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
05/30/2024 and conducted by Evaluator Renita Hall
COMPLAINT CONTROL NUMBER: 08-AS-20240530105122
FACILITY NAME:EUREKA HOMEFACILITY NUMBER:
374604699
ADMINISTRATOR:GONZALEZ, JOSE ADAN, JRFACILITY TYPE:
735
ADDRESS:10746 EUREKATELEPHONE:
(619) 832-6229
CITY:SPRING VALLEYSTATE: CAZIP CODE:
91978
CAPACITY:4CENSUS: 1DATE:
06/05/2024
UNANNOUNCEDTIME BEGAN:
01:47 PM
MET WITH:Jose "Adan" Gonzalez, DirectorTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Staff are not properly trained
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Renita Hall, conducted an unannounced visit to open a complaint and deliver findings regarding the above-mentioned allegation LPA was allowed entry by Jose "Adan" Gonzalez, Director. LPA identified herself and disclosed the purpose of the visit and elements of the findings to the Director.

On May 30, 2024, the Department received a complaint regarding staff are not properly trained. On June 5, 2024, LPA conducted interviews with staff members and resident. Training records and incident reports were reviewed. Documents revealed all staff members had the required training in de-escalating in December 2023. Direct observations of staff-resident interaction no issues and concerns were observed.

Continued on 9099C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Renita Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 06/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/05/2024
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-20240530105122
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: EUREKA HOME
FACILITY NUMBER: 374604699
VISIT DATE: 06/05/2024
NARRATIVE
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Staff stated that the resident had only been at the facility for a couple of weeks and it is an adjustment period for them. Staff had concerns brought up to outside sources for "mood swings." Resident 1 (R1) had been issued medication for the mood swings. R1 stated that they have tried different things to help such as basketball, watching movies, and listening to music and that those hobbies have not helped. R1 acknowledged that the medication hasn't started working yet, and would like to do more socializing with others to help with their emotions. R1 had changed schools and home location within the last three weeks.

Based on the investigation findings, the allegation made against the facility is unsubstantiated. A finding that is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violations occurred.

An exit interview was conducted and a copy of this report along with the Licensee Rights (LIC 9058) was provided to the Director. His signature on this form confirms receipt of the documents.
SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Renita Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 06/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/05/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2