331800058-4-13-2021-18-AS-JESL-CDHVYE-20220415165101

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 331800058
Report Date: 04/13/2021
Date Signed: 04/13/2021 11:33:13 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
02/17/2021 and conducted by Evaluator Javina George

COMPLAINT CONTROL NUMBER: 18-AS-20210217150841

FACILITY NAME:	A B CARING SENIOR LIVING		FACILITY NUMBER:	331800058
ADMINISTRATOR:	CARRASCO, REBECCA		FACILITY TYPE:	740
ADDRESS:	1698 ALBERHILL STREET		TELEPHONE:	(951) 928-0004
CITY:	PERRIS	STATE: CA	ZIP CODE:	92571
CAPACITY:	6	CENSUS: 4	DATE:	04/13/2021
		UNANNOUNCED	TIME BEGAN:	11:15 AM
MET WITH:			TIME COMPLETED:	12:20 PM

ALLEGATION(S):

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Uncleared adult living in the home.
Facility Residents were relocated without department approval.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Javina George and Licensing Program Manager (LPM) Joel Esquivel arrived at the facility unannounced visit to deliver findings for the above allegation(s).

Allegation: Uncleared adult living in the home.
LPA interviewed Licensee/Administrator whom admitted that there was in fact an uncleared adult living in the home. The uncleared adult moved out of the facility on 2/15/21. However the individual was still coming to the facility to assist with tasks at the facility. Based on information provided the allegationof uncleared adult living in the home 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.

Allegation: Facility Residents were relocated without department approval.
LPA interviewed Licensee/Administrator whom stated that due to the circumstances

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Joel Esquivel	TELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javina George	TELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:	DATE: 04/13/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/13/2021

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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Control Number 18-AS-20210217150841

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: A B CARING SENIOR LIVING	FACILITY NUMBER: 331800058
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/13/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 04/27/2021 Section Cited CCR 87355(b)	1 2 3 4 5 6 7	87355 Criminal Record Clearance (b) Prior to the Department issuing a license, the applicant, administrator and any adults other than a client, residing in the facility shall have a criminal record clearance or exemption. This requirement is not met as evidenced by: 1 out of 1 adult is not cleared to be at the facility. This poses a potential health, safety or personal rights risk to person's in care.	1 2 3 4 5 6 7	The licensee will not have Marc at the facility until the paperwork has been submitted and approved to have Marc N. associated to the facility by 5pm on the due date indicated.
	8 9 10 11 12 13 14		8 9 10 11 12 13 14
Type B 04/27/2021 Section Cited CCR 80061(b)(e)	1 2 3 4 5 6 7	80061 Reporitng requirements (b) Upon the occurrence, during the operation of the facility, of any of the events specified in ...information specified in (2) below shall be submitted to the licensing agency within seven days following the occurrence of such event. (E) Any unusual incident or client absence which threatens the physical or emotional health or safety of any client.	1 2 3 4 5 6 7	The licensee will conduct an inservice on reporting requirements and submit proof by 5pm to the department on the due date indicated.
	8 9 10 11 12 13 14	Based on observation, interviews and record review, the licensee did not notfiy the department of the intent to relocate 3 out of 3 residents which poses an immediate health, safety, and personal rights risk to person in care.	8 9 10 11 12 13 14

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 Esquivel	TELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javina George	TELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:	DATE: 04/13/2021

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/13/2021

LIC9099 (FAS) - (06/04)

Page: 3 of 3

Control Number 18-AS-20210217150841

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: A B CARING SENIOR LIVING	FACILITY NUMBER: 331800058
	VISIT DATE: 04/13/2021

NARRATIVE

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involving a staff that was recently terminated, she felt that it was in the best interest to relocate the residents without prior approval from the department. The allegation of Facility Residents were relocated without department approval 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 conducted and a copy of this report, 9099C, 9099D, and appeal rights were provided to Licensee Rebecca Carrasco,

SUPERVISOR'S NAME: Joel Esquivel	TELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javina George	TELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:	DATE: 04/13/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/13/2021

LIC9099 (FAS) - (06/04)

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