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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 335530128
Report Date: 10/25/2024
Date Signed: 10/25/2024 10:12:53 AM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 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
10/01/2024 and conducted by Evaluator Mary Rico
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20241001132605
FACILITY NAME:EARLY BIRD CARE HOMEFACILITY NUMBER:
335530128
ADMINISTRATOR:CHANTHARASETH,PATSARAFACILITY TYPE:
740
ADDRESS:11860 CONFLUENCE DRTELEPHONE:
(951) 268-6525
CITY:JURUPA VALLEYSTATE: CAZIP CODE:
91752
CAPACITY:6CENSUS: 5DATE:
10/25/2024
UNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Licensee William Choi and Licensee Patsara ChantharasethTIME COMPLETED:
10:30 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff handles resident in a rough manner.
Staff isolated resident from other residents in the facility.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Mary Rico conducted an unannounced visit to deliver findings on the allegations listed above. LPA met with Licensee William Choi and Licensee Patsara Chantharaseth explained the purpose of the visit. The investigation consisted of staff interviews, resident interviews and record review.

LPA Rico conducted (4) staff interviews and (3) resident interviews.

For the allegation, Staff handles resident in a rough manner.

During staff interviews, 4 out of the 4 staff stated they have not handled their residents in a rough manner. 4 out of the 4 staff also stated they have not witnessed a staff assist a resident in a rough manner.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Mary Rico
LICENSING EVALUATOR SIGNATURE:

DATE: 10/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2024
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 56-AS-20241001132605
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: EARLY BIRD CARE HOME
FACILITY NUMBER: 335530128
VISIT DATE: 10/25/2024
NARRATIVE
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During resident interviews, 2 out of the 3 residents stated staff have not assisted them in rough manner. 1 out of the 3 resident’s was unable to corroborate on the above allegation. In addition, LPA requested video surveillance from the facility’s common areas. LPA did not observe R1 be assisted in a rough manner.

For the allegation, Staff isolated resident from other residents in the facility.

During staff interviews, 4 out of the 4 staff stated they have not isolated resident from other residents in the facility. 3 out of the 4 staff stated that they encourage residents to be in the common areas and participate in activities.

During resident interviews, 2 out of the 3 residents stated they are allowed to spend time with other residents in the living room, dining area and patio. 2 out 3 residents stated they have not felt isolated. 1 out of the 3 resident’s was unable to corroborate on the above allegation.

Based on the evidence found during the investigation, the two (2) allegations listed above are deemed UNSUBSTANTIATED. A finding that the complaints are UNSUBSTANTIATED means although the allegation may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. During today’s visit, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations.


An exit interview was conducted, and this report (LIC9099) was discussed and provided to Licensee William Choi and Licensee Patsara Chantharaseth

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Mary Rico
LICENSING EVALUATOR SIGNATURE:

DATE: 10/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2024
LIC9099 (FAS) - (06/04)
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