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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 336427424
Report Date: 06/01/2022
Date Signed: 06/01/2022 11:15:30 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, 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
05/24/2022 and conducted by Evaluator Ryan Gardner
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20220524142158
FACILITY NAME:ADEL'S VILLAFACILITY NUMBER:
336427424
ADMINISTRATOR:WILLIAMS, ADELAIDEFACILITY TYPE:
740
ADDRESS:1513 WESLEY STREETTELEPHONE:
(909) 278-1720
CITY:BANNINGSTATE: CAZIP CODE:
92220
CAPACITY:6CENSUS: 4DATE:
06/01/2022
UNANNOUNCEDTIME BEGAN:
08:56 AM
MET WITH:Aminat Molade-House ManagerTIME COMPLETED:
11:25 AM
ALLEGATION(S):
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Staff is not meeting residents medical needs.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Ryan Gardner conducted an unannounced visit to the facility for the purpose of initiating an investigation and delivering findings for the above complaint allegation. LPA Gardner met with Caregiver Theresa Okoro and House Manager Aminat Molade. At the time of visit there were two (2) staff and four (4) residents present.

LPA Gardner toured the facility, interviewed two (2) staff members (S1 & S2), observed resident (R1), and attempted to interview resident (R1). LPA Gardner was not able to interview resident (R1) due to the resident’s level of verbal communication.

LPA Gardner reviewed and obtained resident's (R1) case sheet, hospice records, hospice facility visit summary, and hospice physician orders. There was no evidence found during the investigation to collaborate the above allegation.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Ryan Gardner
LICENSING EVALUATOR SIGNATURE:

DATE: 06/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/01/2022
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-20220524142158
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: ADEL'S VILLA
FACILITY NUMBER: 336427424
VISIT DATE: 06/01/2022
NARRATIVE
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Based on observation, interviews conducted, and record review the allegation is deemed to be UNSUBSTANTIATED.

A finding of UNSUBSTANTIATED means that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur.

Based on observation, interviews conducted, and record review made 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 was discussed and provided to House Manager Aminat Molade, along with a copy of the appeal rights.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Ryan Gardner
LICENSING EVALUATOR SIGNATURE:

DATE: 06/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/01/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2