507004675-7-5-2023-27-AS-SRIN-CU96GF-20230730204752

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 507004675
Report Date: 07/05/2023
Date Signed: 07/05/2023 11:50:26 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, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/02/2023 and conducted by Evaluator Albert Johnson

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20230502164144

FACILITY NAME:	SUBLIME ADULT RESIDENTIAL, INC.		FACILITY NUMBER:	507004675
ADMINISTRATOR:	RODRIGUEZ YIEN, ELIZABETH		FACILITY TYPE:	735
ADDRESS:	1525 DEL MAR AVENUE		TELEPHONE:	(209) 549-9282
CITY:	MODESTO	STATE: CA	ZIP CODE:	95350
CAPACITY:	5	CENSUS: 4	DATE:	07/05/2023
		UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	E Yien		TIME COMPLETED:	12:00 PM

ALLEGATION(S):

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Resident sustained an unexplained injury while in care

INVESTIGATION FINDINGS:

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LPA was able to establish that the resident is transported by Storers and that there are serveral other residents that ride with R1. The driver for R1 denied witnessing or being party to the injury sustained by R1. The care home staff including the Adminstrator denied witnessing or being party to the injury sustained by R1 and the staff at the day program also denied witnessing or being party to the injury sustained by R1.

Based on this investigation, LPA was unable to determine how or where the bruise occurred. LPA was also unable to determine if this resident obtained injuries as a result of another resident's aggressive act, self injurious behaviors, facility staff, day program staff or by other means.

LPA finds allegation to be (US)Unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Exit interview and report provided.

Unsubstantiated

Estimated Days of Completion: 0

SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE:	DATE: 07/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/05/2023

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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