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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331800086
Report Date: 11/25/2024
Date Signed: 11/25/2024 03:09:18 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 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
03/01/2022 and conducted by Evaluator Ruth Martinez
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20220301090049
FACILITY NAME:CALIFORNIA HOME FOR THE ADULT DEAF (CHAD)FACILITY NUMBER:
331800086
ADMINISTRATOR:DANNY BARRETTFACILITY TYPE:
740
ADDRESS:3615 CROWELL AVETELEPHONE:
(626) 701-8960
CITY:RIVERSIDESTATE: CAZIP CODE:
92504
CAPACITY:6CENSUS: 5DATE:
11/25/2024
UNANNOUNCEDTIME BEGAN:
08:00 PM
MET WITH:Barbara Smith-enosTIME COMPLETED:
10:00 PM
ALLEGATION(S):
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Staff member refused t give a resident their medication.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Ruth Martinez visited the facility to further investigate into the above identified complaint allegation. LPA arrived at facility and was greeted at the door by Barbara Smith-enos, caregiver and granted entry and LPA explained the purpose of the visit.

Findings are based upon this investigation which included a tour of the physical plant of the facility, records review, interviews with the following: 5 out of 5 residents, and staff.

It is alleged staff member refused to give a resident their medication. LPA Martinez observed and reviewed medication that is locked in the kitchen cabinet and observed medication to be accurate for all five residents. Records collected by LPA Torres on visit conducted on March 10, 2022, revealed for resident

Continued on LIC9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Ruth Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 11/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/25/2024
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 18-AS-20220301090049
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: CALIFORNIA HOME FOR THE ADULT DEAF (CHAD)
FACILITY NUMBER: 331800086
VISIT DATE: 11/25/2024
NARRATIVE
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(R1) Tylenol is a PRN medication. MAR sheets for February, March 2022 reflect that R1’s PRN medication for Tylenol was given and listed under the PRN medication list. Interview with staff indicated that R1 is able to ask for medication when needed and it is given without a problem or has never had a problem giving the medication to R1. Interview with 5 of 5 residents indicated that they have never experienced an issue with medication, staff give them their medication and they are able to request it when needed and staff will assist them to obtain the medication. Indicated that they have never had an issue in the past or now with getting their medication or pain medication either. They always get it when they request it and have not had an issues to report.

Based on the information mentioned above, the Department is unable to ascertain if the allegation occurred as reported. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, this allegation is deemed Unsubstantiated.

An exit interview was conducted with facility representative and a copy of this LIC9099 report was left at facility.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Ruth Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 11/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/25/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2