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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374601463
Report Date: 03/28/2023
Date Signed: 03/28/2023 12:15:48 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, 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
03/24/2023 and conducted by Evaluator Venus Mixson
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20230324113420
FACILITY NAME:CAMELOTFACILITY NUMBER:
374601463
ADMINISTRATOR:MOSS, JUDITHFACILITY TYPE:
735
ADDRESS:2035 ALTA VISTA DRIVETELEPHONE:
(760) 724-7898
CITY:VISTASTATE: CAZIP CODE:
92084
CAPACITY:6CENSUS: 3DATE:
03/28/2023
UNANNOUNCEDTIME BEGAN:
10:40 AM
MET WITH:LEAD CAREGIVER, RACHEL ALVAREZ.TIME COMPLETED:
12:35 PM
ALLEGATION(S):
1
2
3
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5
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7
8
9
Facility is malodorous.
Facility has insects.
Facility is unsanitary.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On March 28, 2023, Licensing Program Analyst (LPA), Venus Mixson arrived unannounced in order to conducted an investigation into the above listed allegations. LPA Mixson was greeted and granted entry by Lead Caregiver, introduced self and stated the purpose of the visit.
Present in the facility are three residents and two staff. LPA Mixson toured the facility with the Lead Caregiver and made observations regarding the listed allegations. LPA Mixson interviewed the Administrator via the telephone, the Lead Caregiver, and one Resident. LPA Mixson requested and received pertinent documentation. There were no issues or concerns observed. There were no health and/or safety issues observed on this visit. After LPA's evaluation of staff and resident interviews, and observations, there was not enough evidence to demonstrate if the listed allegations did or did not occur. Therefore, the findings of the listed allegations is Unsubstantiated. Unsubstantiated means "Although the alleged allegations could have happened there is not a preponderance of the evidence to state if the allegations did or did not occur."
An exit interview was conducted with the Lead Caregiver and a copy of this report, along with the LIC 811, was provided to Lead Caregiver.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Jazmond D HarrisTELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Venus MixsonTELEPHONE: (951) 897-7936
LICENSING EVALUATOR SIGNATURE:

DATE: 03/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2023
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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