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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 336425978
Report Date: 07/31/2023
Date Signed: 07/31/2023 03:17:22 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
, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/28/2023 and conducted by Evaluator Javier Prieto
COMPLAINT CONTROL NUMBER: 56-AS-20230728091428

FACILITY NAME:LIVE IN COMFORT CAREFACILITY NUMBER:
336425978
ADMINISTRATOR:GOMEZ, KECIAFACILITY TYPE:
740
ADDRESS:9872 WOODBRIDGE LANETELEPHONE:
(909) 643-6965
CITY:RIVERSIDESTATE: CAZIP CODE:
92509
CAPACITY:6CENSUS: 5DATE:
07/31/2023
UNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Kecia Gomez, Administrator TIME COMPLETED:
03:15 PM
ALLEGATION(S):
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Staff did not file an unusual incident report with CCL
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Javier Prieto made an unannounced visit to the facility to conduct a complaint investigation regarding the above allegations. LPA Javier met with Administrator Kecia Gomez and discussed the purpose of the visit. The investigation consisted of direct observations and interviews with staff.

Regarding the allegation of staff did not file an unusual incident report with CCL, administrator Gomez produced copies of faxed confirmation to the State Licensing for a period of approximately 5 months. Copies of the recent incident reports were also obtained during this visit.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Javier Prieto
LICENSING EVALUATOR SIGNATURE:

DATE: 07/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/31/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 56-AS-20230728091428
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME: LIVE IN COMFORT CARE
FACILITY NUMBER: 336425978
VISIT DATE: 07/31/2023
NARRATIVE
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Based on the information obtained there is not enough evidence that staff did not file an unusual incident report with CCL. Therefore, the allegations is deemed UNSUBSTANTIATED at this time. A copy of this report was signed by LPA Prieto and Administrator Gomez and a copy was left with the facility.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Javier Prieto
LICENSING EVALUATOR SIGNATURE:

DATE: 07/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/31/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3