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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 336427578
Report Date: 11/01/2021
Date Signed: 11/01/2021 01:55:31 PM

Unfounded


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
RIVERSIDE, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/26/2021 and conducted by Evaluator David Cuevas
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20211026145339
FACILITY NAME:FOOTHILL LAKE HOMEFACILITY NUMBER:
336427578
ADMINISTRATOR:ANGELITO V. MENDOZAFACILITY TYPE:
740
ADDRESS:24746 MORNING MIST DRIVETELEPHONE:
(951) 208-1722
CITY:MORENO VALLEYSTATE: CAZIP CODE:
92557
CAPACITY:6CENSUS: 4DATE:
11/01/2021
UNANNOUNCEDTIME BEGAN:
12:25 PM
MET WITH:Administrator, Julita Mendoza TIME COMPLETED:
02:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff yells at a resident while in care
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) David Cuevas conducted an unannounced visit to the facility to initiate an investigation to allegation above. LPA met with caregiver, Ms. Manuel who was informed of the purpose of visit. Ms. Manuel called Administrator, Julita Mendoza who arrived at the facility shortly after.

During this investigation LPA conducted records review, direct observations, and interviews with staff and residents.

Regarding allegation: Staff yells at a resident while in care

During visit LPA interviewed a total of (5) individuals’ available, staff and residents. Per collected interviews 5 out of 5 interviewees communicated to have no knowledge of or witnessing staff yelling at Resident # 1 (R1) while in care. Furthermore, all resident in care expressed being content with placement and to have not witness any staff yelling at any resident. Additionally, interviews with Staff # 1(S1) and staff # 2 (S2) deny any occurrence in which staff yelled at R1 or any other resident in care at facility, as such based on interviews and collected evidence, the allegation of Staff yells at a resident in care is UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without reasonable basis.

An exit interview was conducted where a copy of this report was discussed and provided to Administrator, Julita Mendoza.
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: David Cuevas
LICENSING EVALUATOR SIGNATURE:

DATE: 11/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2021
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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