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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 366424647
Report Date: 10/07/2021
Date Signed: 10/07/2021 10:35:59 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
RIVERSIDE, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/14/2021 and conducted by Evaluator Stephanie Williams
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20210114131928
FACILITY NAME:ANDREW CARE CENTERFACILITY NUMBER:
366424647
ADMINISTRATOR:LAYGO, ADRIANFACILITY TYPE:
740
ADDRESS:13821 CRONESE WAYTELEPHONE:
(760) 946-5829
CITY:APPLE VALLEYSTATE: CAZIP CODE:
92307
CAPACITY:6CENSUS: 4DATE:
10/07/2021
UNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:TIME COMPLETED:
10:45 AM
ALLEGATION(S):
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Neglect resulting in death of client
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Stephanie Williams made an unannounced visit to the facility in order to deliver findings for the above allegation. LPA identified herself and discussed the purpose of the visit with Caregiver, Sergio Sanchez. The investigation consisted of records review and interviews with staff, clients, and witnesses.

LPA Williams reviewed a copy of Client #1’s (C1’s) Death Certificate which listed C1’s immediate cause of death as Cardiopulmonary Arrest. The Death Certificate also listed the underlying causes of death as Diabetes and Hypertension, with the time interval between onset of condition and death listed as “years.” LPA interviewed Staff #1 (S1) who stated that C1 had numerous health conditions which led to C1 being in and out of the hospital. S1 denied neglect and stated that facility staff provided appropriate care for C1 as well as the other clients. LPA interviewed C1’s Public Conservator (PC), who stated that they believe facility staff took appropriate care of C1 prior to passing. PC denied that C1’s death was a result of neglect by the facility. LPA reviewed C1's records in which it appeared that C1 was being seen by a physician/receiving medical attention on a consistent basis.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Stephanie Williams
LICENSING EVALUATOR SIGNATURE:

DATE: 10/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2021
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 18-AS-20210114131928
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
RIVERSIDE, CA 92507
FACILITY NAME: ANDREW CARE CENTER
FACILITY NUMBER: 366424647
VISIT DATE: 10/07/2021
NARRATIVE
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Based on evidence obtained during the investigation, LPA has determined that the above allegation is UNSUBSTANTIATED; meaning 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.

An exit interview was conducted where this report was discussed and a copy was provided to the at the conclusion of the visit.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Stephanie Williams
LICENSING EVALUATOR SIGNATURE:

DATE: 10/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 2