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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331800001
Report Date: 07/18/2023
Date Signed: 07/18/2023 10:15:42 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
RIVERSIDE, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/27/2023 and conducted by Evaluator Javina George
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20230327120802
FACILITY NAME:TERRA LAGO ASSISTED LIVINGFACILITY NUMBER:
331800001
ADMINISTRATOR:CHOUDRY, SAHERFACILITY TYPE:
740
ADDRESS:84701 VELIERO CTTELEPHONE:
(760) 342-3627
CITY:INDIOSTATE: CAZIP CODE:
92203
CAPACITY:6CENSUS: 5DATE:
07/18/2023
UNANNOUNCEDTIME BEGAN:
08:50 AM
MET WITH:Saif Choudry,CaregiverTIME COMPLETED:
10:20 AM
ALLEGATION(S):
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Resident was left in a soiled diaper for a long period of time.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Javina George made an unannounced visit to the facility to deliver findings for the allegation listed above. LPA George met with Saif Choudry,Caregiver and LPA informed of the purpose of the visit and the elements of the allegation. The allegation was investigated and consisted of observation, interviews and record review.

Regarding the allegation of resident was left in a soiled diaper for a long period of time. It was reported that on or around March 20, 2023, Resident #1 (R1) reported that they needed their diaper changed. At the time of the incident the facility had a census of 4 residents and 1 staff working. The facility has a live in caregiver that is expected to assist when the resident has a need. Per an interview with R1 stated that they did not know how to alert staff, and that they had called out to staff for help, however there was no response. R1 believes that they had been waiting for maybe an hour. LPA conducted a review of records (social media post), that was made at 3:59am revealed R1 did in fact make an attempt to contact staff and there was no response. ***Continued on 9099C.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javina GeorgeTELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:

DATE: 07/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/18/2023
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-20230327120802
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: TERRA LAGO ASSISTED LIVING
FACILITY NUMBER: 331800001
VISIT DATE: 07/18/2023
NARRATIVE
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Per the Administrator Sahir states that S1 changed R1’s diaper at 4:45am, this information was confirmed, and revealed that R1 waited for 46 minutes. The facility is not equipped with a call system and relies on sound monitors to alert staff that a resident is in need of assistance. The sound monitor is centrally located in the hallway sitting on the to of the cabinet, and is in the middle of all the resident bedrooms. S1 states that the residents are checked every hour. Based on interviews and record review the allegation of resident was left in a soiled diaper for a long period of time 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. A citation will be issued in accordance with the California Code of Regulations (Title 22, Division 6, Chapter 8), on the attached 9099D.


An exit interview was conducted and a copy of this report 9099C, 9099D and appeal rights were provided to Saif Choudry.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javina GeorgeTELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:

DATE: 07/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/18/2023
LIC9099 (FAS) - (06/04)
Page: 5 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
RIVERSIDE, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/27/2023 and conducted by Evaluator Javina George
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20230327120802

FACILITY NAME:TERRA LAGO ASSISTED LIVINGFACILITY NUMBER:
331800001
ADMINISTRATOR:CHOUDRY, SAHERFACILITY TYPE:
740
ADDRESS:84701 VELIERO CTTELEPHONE:
(760) 342-3627
CITY:INDIOSTATE: CAZIP CODE:
92203
CAPACITY:6CENSUS: 6DATE:
07/18/2023
UNANNOUNCEDTIME BEGAN:
08:50 AM
MET WITH:Saif Choudry,CaregiverTIME COMPLETED:
10:20 AM
ALLEGATION(S):
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Facility did not provide a safe environment for residents in care.
Facility denied Law enforcement access to enter the facility.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Javina George made an unannounced visit to the facility to deliver findings for the allegation(s) listed above. LPA George met with Saif Choudry,Caregiver and informed them of the purpose of the visit and the elements of the allegation(s). The allegation was investigated and consisted of observation, interviews and record review.

Regarding the allegation facility did not provide a safe environment for residents in care.
It was reported that on or around March 21, 2023, staff #1 (S1) prevented Resident #2 (R2) from hitting R1. R2 is reported by facility staff as them being known to wander throughout the facility and into other resident rooms. R2 also likes to lay down on an empty bed located inside of R1’s bedroom. A review of records revealed that S1 had allegedly prevented S2 from hitting R1, however S1 denied that the alleged incident occurred. R1 had expressed that they were afraid of R2 since they had allegedly tried to hit them. If the incident did happen, it is reported that the staff did intervene and prevent R1 from being hit by R2. Therefore, the allegation of facility did not provide a safe environment for residents in care is UNFOUNDED.
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javina GeorgeTELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:

DATE: 07/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/18/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 18-AS-20230327120802
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: TERRA LAGO ASSISTED LIVING
FACILITY NUMBER: 331800001
VISIT DATE: 07/18/2023
NARRATIVE
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Facility denied Law enforcement access to enter the facility.

Regarding the allegation facility denied law enforcement access to enter the facility. It was alleged that on or around March 21, 2023, staff #1 (S1) prevented Resident #2 (R2) from hitting R1. R2 is reported by facility staff as them being known to wander throughout the facility and into other resident rooms. R2 also likes to lay down on an empty bed located inside of R1’s bedroom. A review of records revealed that S1 had allegedly prevented S2 from hitting R1, however S1 denied that the alleged incident occurred. R1 had expressed that they were afraid of R2 since they had allegedly tried to hit them. As a result report law enforcement was contacted and responded to the facility. However, there was no evidence to corroborate that law enforcement being denied entry. Therefore, the allegation facility denied Law enforcement access to enter the facility is UNFOUNDED. A finding that the complaint is unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis.

An exit interview was conducted and a copy of this report was provided to Saif Choiudry, Caregiver.

SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javina GeorgeTELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:

DATE: 07/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/18/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 18-AS-20230327120802
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: TERRA LAGO ASSISTED LIVING
FACILITY NUMBER: 331800001
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/18/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/01/2023
Section Cited
CCR
87468.2(a)(4)
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87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights:
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The licensee failed to ensure that 1 out of 1 times R1 was given the care and supervision based on their needs. This poses a potential health safety and personal rights risk to persons in care.
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(4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. Based on observation and interviews this requirement is not met as evidenced by:
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The licensee agrees to an inservice incontinent care, when to peform checks and change the residents.
Proof of the completed POC is due by 5pm on 08/01/2023.
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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.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javina GeorgeTELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:

DATE: 07/18/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/18/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 5