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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 372004630
Report Date: 11/18/2024
Date Signed: 12/16/2024 11:40:01 AM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 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
11/13/2024 and conducted by Evaluator Janette Romero
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20241113162414
FACILITY NAME:COUNTRY CLUB GUEST HOMEFACILITY NUMBER:
372004630
ADMINISTRATOR:RAMIREZ, JULIEFACILITY TYPE:
740
ADDRESS:25533 RUA MICHELLETELEPHONE:
(760) 747-0957
CITY:ESCONDIDOSTATE: CAZIP CODE:
92026
CAPACITY:30CENSUS: 27DATE:
11/18/2024
UNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Caregiver, Victoria MatthewsTIME COMPLETED:
02:25 PM
ALLEGATION(S):
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Staff physically and emotionally abused resident
INVESTIGATION FINDINGS:
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On 12/16/2024, Licensing Program Analyst (LPA), Janette Romero arrived unannounced to deliver amended investigative findings regarding the allegation listed above. LPA met with Caregiver, Victoria Matthews who was informed of the purpose of the visit. Licensee, Julie Ramirez was contacted over the phone and also informed of the purpose of the visit.

It was alleged Resident 1 (R1) was being physically and emotionally abused by Staff 1 (S1) and R1 sustained multiple bruises on their forearm and back of leg. It was not described how R1 is allegedly emotionally abused. LPA toured the facility, made a collateral visit, conducted resident, staff, and witness interviews and obtained copies of pertinent documentation. LPA made a collateral visit to R1's day program and observed R1 with multiple bruises on their forearms and back of leg. A witness interview conducted revealed R1 has been observed at day program with bruises on their forearms since 2023 but the day program did not suspect abuse from facility staff. Information gathered during an interview with R1 did not refute nor corroborate the allegation. LPA attempted to conduct an interview with R1's roommate, however they refused to be interviewed.

*This is an amended version of the original report.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Janette Romero
LICENSING EVALUATOR SIGNATURE:

DATE: 12/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2024
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-20241113162414
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: COUNTRY CLUB GUEST HOME
FACILITY NUMBER: 372004630
VISIT DATE: 11/18/2024
NARRATIVE
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Two (2) facility staff were interviewed and reported they have never observed S1 abuse R1 or any other resident. S1 was interviewed and reported they have never hit or abused R1. Licensee Ramirez was interviewed and reported R1 receives home health services at the facility twice per week. LPA contacted the home health agency who reported due to R1's diagnosis, R1 sustains substantial bruises with minor contact, including when receiving transfer assistance. The home health agency added they do not suspect R1 is being abused by facility staff and there are no concerns with the type of care and supervision R1 is receiving at the facility. This agency has investigated the complaint alleging "Staff physically and emotionally abused resident". Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. An exit interview was conducted and this report was reviewed with Licensee Ramirez over the phone and a copy of this report was provided to Caregiver Matthews along with a Confidential Names list (LIC 811).

*This is an amended version of the original report.
SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Janette Romero
LICENSING EVALUATOR SIGNATURE:

DATE: 12/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2