197607345-10-31-2022-31-AS-RRAZ-CLL4PF-20221127181639

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197607345
Report Date: 10/27/2022
Date Signed: 10/31/2022 08:19:00 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, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/16/2022 and conducted by Evaluator Melissa Spaeth

COMPLAINT CONTROL NUMBER: 31-AS-20220616084516

FACILITY NAME:	IVAN BANNER BOARDING CARE		FACILITY NUMBER:	197607345
ADMINISTRATOR:	CYNTHIA TAYLOR		FACILITY TYPE:	740
ADDRESS:	39409 DAYLILY PLACE		TELEPHONE:	(661) 267-0779
CITY:	PALMDALE	STATE: CA	ZIP CODE:	93551
CAPACITY:	6	CENSUS: 3	DATE:	10/27/2022
		UNANNOUNCED	TIME BEGAN:	11:30 AM
MET WITH:	Donald Fagen		TIME COMPLETED:	01:45 PM

ALLEGATION(S):

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Staff touched resident inappropriately

INVESTIGATION FINDINGS:

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LPA Spaeth conducted an unannounced visit and was greeted by Caregiver. LPA stated the purpose of the visit was to complete the investigation for the allegation, staff touched resident inappropriately. Upon entering the facility, LPA's temperature was taken and recorded. LPA observed the caregiver was wearing a mask. Caregiver confirmed there are three residents at the facility.

LPA and Caregiver took a tour of the facility at 11:40 pm until 12:00 noon. LPA did not observe any health or safety issues. LPA interviewed the caregiver and Administrator at 12 10 until 12 25 pm. LPA reviewed resident's file at 12:30 pm until 12:40 pm.

A complaint was received on 06/16/2022 which alleged Resident #1 (R1) had been inappropriately touched by a staff member. The complaint investigation was conducted by Investigations Branch (IB) Investigator Olivia Spindola. Investigator Spindola spoke to R1’s Conservator on 6/29/2022 at 1:00 pm who stated R1

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE:	DATE: 10/27/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2022

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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Control Number 31-AS-20220616084516

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: IVAN BANNER BOARDING CARE	FACILITY NUMBER: 197607345
	VISIT DATE: 10/27/2022

NARRATIVE

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was moved to another facility on 6/14/2022 due to the allegation in question. Investigator Spindola interviewed R1 at the new residence on 7/05/2022, 11:00 am. During the interview, R1 was unable to recall or remember the alleged incident and could not recall the name of the alleged abuser. Investigator Spindola asked if R1 had been sexually abused by another person. R1 stated no. Based upon Investigator Spindola’s interview of R1 and LPA’s interview of the caregiver and the Administrator, this allegation is unsubstantiated.

Exit interview conducted, appeal rights discussed, and a copy of the report was given to the Caregiver.

SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE:	DATE: 10/27/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2022

LIC9099 (FAS) - (06/04)

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