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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331800058
Report Date: 12/21/2021
Date Signed: 12/21/2021 01:34:15 PM

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
01/20/2021 and conducted by Evaluator Javina George
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20210120170507
FACILITY NAME:A B CARING SENIOR LIVINGFACILITY NUMBER:
331800058
ADMINISTRATOR:CARRASCO, REBECCAFACILITY TYPE:
740
ADDRESS:1698 ALBERHILL STREETTELEPHONE:
(951) 928-0004
CITY:PERRISSTATE: CAZIP CODE:
92571
CAPACITY:6CENSUS: 0DATE:
12/21/2021
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Rebecca Carrasco, LicenseeTIME COMPLETED:
01:45 PM
ALLEGATION(S):
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Resident's developed a rash while in care.
Staff using foul language in the presence of resident's.
Staff engaging in physical altercations in resident's presence.
Resident sustained an injury while in care.
INVESTIGATION FINDINGS:
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 ****This report is an amendment to the findings delivered and supercedes the original report dated April 13, 2021.
Licensing Program Analyst (LPA) Javina George and Licensing Program Manager (LPM) Joel Esquivel arrived at the facility unannounced to deliver findings for the above allegation(s).

Allegation: Resident's developed a rash while in care.
On 2/18/21 LPA George conducted an unannounced visit and observed Resident #1 (R1) to have a rash located on the resident's stomach and chest. Based on interviews, observations and documentation gathered; LPA was able to corroborate the allegation. The allegation Resident's developed a rash while in care 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.


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: 12/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2021
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 3
Control Number 18-AS-20210120170507
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: 12/21/2021
NARRATIVE
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Allegation: Staff using foul language in the presence of resident's.
LPA conducted interviews with staff and residents. Licensee admitted that there were times when foul language was used towards another staff in front of the residents. Based on the feedback provided the allegation of Staff using foul language in the presence of resident's 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: Staff engaging in physical altercations in resident's presence.
LPA reviewed documentation related to an altercation between Licensee and Staff # (S1). Both the Licensee and S1 admitted that there was an altercation that took place in front of the residents. Due to self admission the allegation of Staff engaging in physical altercations in resident's presence 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: Resident sustained an injury while in care.
On 2/18/21 LPA George conducted an unannounced visit and observed (R1) to have sores located on the side left of their back. Based on interviews, observations and documentation gathered; LPA was able to corroborate the allegation. The allegation of Resident sustained an injury while in care 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, 811-confidential names list and appeal rights were provided to Licensee Rebecca Carrasco,
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javina GeorgeTELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:

DATE: 12/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 3
Control Number 18-AS-20210120170507
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: 12/21/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/04/2022
Section Cited
CCR
87466
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87466 Observation of the Resident The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. When changes such as unusual weight gains or losses or deterioration of mental ability or a physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any. This requirement is not met as evidenced by: Based on observation and interview the licensee did not ensure that the residents were being monitored regularly which posed a potential health and safety risk to persons in care.
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The licensee agrees to conduct an inservice on Observation of residents in care. The POC is due by 5pm on the due date indicated.
Type B
04/27/2021
Section Cited
CCR
80072(a)(2)
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80072 Personal Rights
a) Except for children’s residential facilities, each client shall have personal rights which include, but are not limited to, the following:
Based on observation, interviews and record review, the licensee did not ensure To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs which poses a potential health, safety, and personal rights risk to person in care.



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The licensee will conduct an inservice on personal rights and submit proof to the department by 5pm on the due date indicated.
Type B
04/27/2021
Section Cited
CCR
80072(a)(1)
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80072(a)(1)
(a) Except for children’s residential facilities, each client shall have personal rights which include, but are not limited to, the following:
(1) To be accorded dignity in his/her personal relationships with staff and other persons. This requirement is not met as evidenced by: based on observation, interview and record review the licensee did not afford the residents to have dignity in their relationship with staff as staff were seen figting and heard using foul language, this poses a potential health, safety or personal rights risk to persons in care.
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The licensee will conduct an inservice on anger management and burn out and submit proof to the department by 5pm on the due date indicated.
Type B
01/04/2022
Section Cited
CCR
80078(a)
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80078 Responsibility for Providing Care and Supervision
(a) The licensee shall provide care and supervision as necessary to meet the client's needs. This requirement is not met as evidenced by: based on observation, interview and record review the licensee did not provide supervision, as a resident sustained an injury while in care. This poses a potential health, and safety risk to persons in care.
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The licensee will conduct an inservice on care and supervision. Proof is to be submitted the department by 5pm on the due date indicated.
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: 12/21/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 3