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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 361880860
Report Date: 02/22/2023
Date Signed: 02/22/2023 11:40:30 AM

Substantiated


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
11/04/2021 and conducted by Evaluator Rayshaun Nickolas
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20211104131634
FACILITY NAME:ALPHALIFE HOMECAREFACILITY NUMBER:
361880860
ADMINISTRATOR:SALDIVAR, BRYANT JFACILITY TYPE:
740
ADDRESS:9154 BELLFAST ROADTELEPHONE:
(909) 601-5154
CITY:APPLE VALLEYSTATE: CAZIP CODE:
92308
CAPACITY:12CENSUS: 3DATE:
02/22/2023
UNANNOUNCEDTIME BEGAN:
10:42 AM
MET WITH:Bryant Saldivar, LicenseeTIME COMPLETED:
11:40 AM
ALLEGATION(S):
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Staff did not allow family member to visit resident.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Rayshaun Nickolas made an unannounced visit to the facility to deliver the finding on the above allegation. LPA met with Licensee Bryant Saldivar and explained the purpose of the visit. The investigation consisted of file reviews, and interviews with relevant parties.

The reporting party (RP) alleged that they were told by staff # 1 (S1) that a relative of resident #1 (R1) could not visit R1 because of their criminal record. The RP was unclear on how S1 found out about R1’s relative’s criminal record because it had nothing to do with them visiting R1. The RP also alleged on another occasion that as the Power of Attorney (POA) for R1, they attempted to make an appointment so R1’s relative could visit. That appointment was canceled by a facility staff member, who also threatened to call the police. LPA interview with the Licensee revealed that R1’s relative was rude and did not make an appointment. The Licensee also advised R1’s relative that the Licensee also needed to check with the POA before permitting the visit. LPA interview with the RP revealed that R1’s relative had been turned away several times because of their criminal record.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Rayshaun Nickolas
LICENSING EVALUATOR SIGNATURE:

DATE: 02/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/22/2023
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 5
Control Number 18-AS-20211104131634
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: ALPHALIFE HOMECARE
FACILITY NUMBER: 361880860
VISIT DATE: 02/22/2023
NARRATIVE
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Based on the evidence gathered during the investigation, the above allegation is substantiated. A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

An exit interview was conduct were a copy of this report (LIC 9099), LIC 9099D, and appeal rights were discussed and provide.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Rayshaun Nickolas
LICENSING EVALUATOR SIGNATURE:

DATE: 02/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/22/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 18-AS-20211104131634
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: ALPHALIFE HOMECARE
FACILITY NUMBER: 361880860
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/22/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type B
02/27/2023
Section Cited
CCR
87355(2)(A)
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87355 Criminal Record Clearance (2)(A)
(2) The following persons are exempt from requirements applicable under paragraph (1): (A) A spouse, relative, significant other, or close friend ...
This requirement was not met as evidenced by:
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The Licensee shall read Title 22, Division 6, of the California Code and Regulation (CCR), Section 87355 (2) (A), and submit a letter of understanding.
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Based on interviews, the licensee did not ensure that the facility staff was adhering to the Title 22 of the California Code and Regulation (CCR), Section 87355 (2)(A), which poses a potential heath, safety, and person rights violation to clients in care.
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The Licensee shall provide training to all staff at the facility and submit proof of training with all facility staff signatures acknowledging proof of training to LPA by the POC due date.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Rayshaun Nickolas
LICENSING EVALUATOR SIGNATURE:

DATE: 02/22/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/22/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 5
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
11/04/2021 and conducted by Evaluator Rayshaun Nickolas
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20211104131634

FACILITY NAME:ALPHALIFE HOMECAREFACILITY NUMBER:
361880860
ADMINISTRATOR:SALDIVAR, BRYANT JFACILITY TYPE:
740
ADDRESS:9154 BELLFAST ROADTELEPHONE:
(909) 601-5154
CITY:APPLE VALLEYSTATE: CAZIP CODE:
92308
CAPACITY:12CENSUS: 3DATE:
02/22/2023
UNANNOUNCEDTIME BEGAN:
10:42 AM
MET WITH:Bryant Saldivar, LicenseeTIME COMPLETED:
11:40 AM
ALLEGATION(S):
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Staff did not change the resident's clothing.
Staff locked the resident in a room.
llegal Eviction.
Resident is missing personal items
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Rayshaun Nickolas made an unannounced visit to the facility to deliver the finding on the above allegations. LPA met with Licensee Bryant Saldivar and explained the purpose of the visit. The investigation consisted of file reviews and interviews with relevant parties.

Allegation #1 "Staff did not change the resident's clothing." The reporting party (RP) alleged that they took resident # 1 (R1) up on a Saturday and returned them on Monday. The RP alleged that R1 had doctors' appointments on Monday, Tuesday, and Wednesday during the same week, and each day they arrived to pick up R1, R1 was wearing the same clothing. LPA interview with the RP revealed that when they questioned R1 about wearing the same clothing, R1 could not explain why they were in the same clothing. LPA interview with the Licensee revealed that they were unaware that R1 was wearing the same clothing for three (3) consecutive days. - The finding is Unsubstantiated. There is no evidence or witnesses to corroborate the allegation.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Rayshaun Nickolas
LICENSING EVALUATOR SIGNATURE:

DATE: 02/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/22/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 18-AS-20211104131634
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: ALPHALIFE HOMECARE
FACILITY NUMBER: 361880860
VISIT DATE: 02/22/2023
NARRATIVE
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Allegation #2 “Staff locked the resident in a room". The RP alleged that R1 informed them they were locked in a room and unable to come out. LPA interview with the RP revealed that when they questioned R1 about wearing the same clothing, R1 stated they were locked in another room. LPA interview with the Licensee revealed that the Licensee denied that R1 was locked in a room. The finding is Unsubstantiated. There is no evidence or witnesses to corroborate the allegation.

Allegation #3 “illegal Eviction” LPA interview with the RP revealed that R1 was never served with an eviction notice. However, the Licensee stated they would evict R1 when the RP mentioned their intentions to remove R1 from the facility. LPA interview with the Licensee revealed that they did not serve R1’s Power of Attorney (POA) with an eviction notice. The finding is Unsubstantiated. There is no evidence or witnesses to corroborate the allegation.

Allegation # 4: “Resident is missing personal items”. The RP alleged that the RP decided to look for another place for R1 to live and told the Licensee that they would be picking R1 up on 11/5/2021. The RP alleged that the Licensee advised them that R1’s personal belongings needed to be out by noon 11/4/2021 or they would be donated. The RP further alleged that they arrived on 11/4/21 and all R1’s belongings were at the front door, and they were not allowed to go inside to ensure all of R1’s belongings were collected. LPA interview with RP revealed that when they arrived at the facility to pick up R1 and R1’s belongings, they were not allowed inside. The RP stated that the facility staff brought R1 and R1’s items out. The RP further stated that another relative of R1 contacted the License, and the Licensee returned additional items to R1. However, the RP stated that we were never allowed to retrieve R1’s items inside the facility. LPA interview with the Licensee revealed that they coordinated with R1’s POA on a date to move R1 out. The Licensee stated that the original date agreed upon did not work, but the Licensee did work out with the POA to move R1 out a day ahead of schedule. The Licensee stated that after R1 was moved, they found additional items of R1 and returned them to a relative of R1. The finding is Unsubstantiated. There is no evidence or witnesses to corroborate the allegation.

A finding of Unsubstantiated means 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.

An exit interview was conducted and copy of this report was provided.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Rayshaun Nickolas
LICENSING EVALUATOR SIGNATURE:

DATE: 02/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/22/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5