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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331800058
Report Date: 07/12/2023
Date Signed: 07/12/2023 02:18:55 PM

Substantiated


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
10/20/2020 and conducted by Evaluator Chinwe Nwogene
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20201020162344
FACILITY NAME:A B CARING SENIOR LIVINGFACILITY NUMBER:
331800058
ADMINISTRATOR:CARRASCO, REBECCAFACILITY TYPE:
740
ADDRESS:1698 ALBERHILL STREETTELEPHONE:
(951) 224-1247
CITY:PERRISSTATE: CAZIP CODE:
92571
CAPACITY:0CENSUS: 0DATE:
07/12/2023
UNANNOUNCEDTIME BEGAN:
01:50 PM
MET WITH:Rebecca Carrasco, LicenseeTIME COMPLETED:
02:25 PM
ALLEGATION(S):
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Resident sustained severe burns while in care.
Staff failed to prevent resident from wandering while in care.
Staff failed to properly report incidents regarding resident.
INVESTIGATION FINDINGS:
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On 07/12/2023, Licensing Program Analysts (LPA) Chinwe Nwogene conducted an office visit with Licensee, Rebecca Carrasco at the Riverside Adult and Senior Care Regional Office, to deliver the findings on the mentioned allegations. Rebecca Carrasco arrived at the office at 1:50PM.
During the investigation staff, residents, and other relevant persons were interviewed. In addition, facility, medical and law enforcement records were reviewed.
Regarding the allegation “Resident sustained severe burns while in care”, it was alleged Resident (R1) sustained severe burns when getting into a bathtub with scalding water. Interviews with staff revealed, on the night of 10/12/2020, staff (S1) fell asleep and woke up between 3:00-3:30 am to use the restroom. Staff heard someone yell and went into the bathroom and found R1 inside the bathtub, fully clothed, laying sideways in water. Staff tried to pull the drain plug but the “water was too hot.” Staff pulled resident out of the tub, laid resident on the floor, and called 911. Resident was taken to hospital and diagnosed with burns. A review of R1’s ED Trauma Note from date of visit 10/12/2020 reveals: severe distress and 2nd and 3rd degree burns to bilateral lower extremities, arms, back, abdomen: approx. 60% TBSA, circumferential around lower extremities. It was reported by staff that they did not need to be awake at night because residents were fairly independent. Staff further reported the facility did not use monitors, but residents could use a call button to get staff attention. A review of the facility’s program plan revealed facility is to provide 24-hour awake staff. In addition, the program plan revealed the facility provides a call system in every resident bedroom so that residents can summon staff if needed.
Continue on LIC9099-C.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Chinwe NwogeneTELEPHONE: (951) 202-2066
LICENSING EVALUATOR SIGNATURE:

DATE: 07/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/12/2023
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 4
Control Number 18-AS-20201020162344
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: A B CARING SENIOR LIVING
FACILITY NUMBER: 331800058
VISIT DATE: 07/12/2023
NARRATIVE
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Continued from LIC9099.

Administrator, Rebecca Carrasco, reported the residents kept breaking the call system and the facility stopped replacing it about a year ago. R1’s physician report dated 04/09/2019 indicates R1 was slightly confused due to pre dementia / Alzheimer’s, had wandering behavior and could not speak due to prior stroke regarding their ability to communicate their needs. In addition, at the time of the incident, there was at least one resident who required night supervision per the pre-placement appraisal dated 06/01/2020.

Regarding the allegation “Staff failed to prevent resident from wandering while in care”, LPA interviewed staff and Licensee who stated R1 wandered off the facility two to three times. The Licensee reported she could not recall the exact dates. The Licensee stated facility had an operable door alarm, but it didn't stop resident from walking off the facility. Licensee stated staff sometimes do not hear the alarm because they are busy helping other residents or if staff is sleeping. Staff interviews corroborated Licensee’s statements that R1 wandered from the facility on more than one occasion. Staff interviews revealed R1 would wander off when staff were sleeping and would use a chair to get over the fence. Staff interviews did not reveal dates. Licensee stated facility didn’t have a plan in place to mitigate resident from wandering out of the facility without staff supervision.

Regarding the allegation “Staff failed to properly report incidents regarding resident”, the licensee stated R1 had wandered off the facility two to three times. Licensee acknowledged the incidents were not reported to Community Care Licensing Division (CCLD) as required. Licensee stated staff on duty was supposed to do all the paperwork and reporting to CCLD. Staff interviews revealed verbal reports were given to the licensee and the licensee was supposed to report to CCLD.

Based on interviews and record reviews, the preponderance of evidence standard has been met. Therefore, the above allegations are found to be substantiated. California Code of Regulations (Title 22, Division & Chapter number 6 are being cited on the attached LIC 9099D). An exit interview was conducted, and a copy of this report was reviewed and provided along with appeal rights to Rebecca Carrasco. An immediate civil penalty of $500 is being assessed for R1 sustaining burns. In accordance with H&S Code Section 1569.49(e), the determination of additional civil penalties for a violation that resulted in a serious injury to the resident, is pending and under review by the Department.

SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Chinwe NwogeneTELEPHONE: (951) 202-2066
LICENSING EVALUATOR SIGNATURE:

DATE: 07/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/12/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 18-AS-20201020162344
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: A B CARING SENIOR LIVING
FACILITY NUMBER: 331800058
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/12/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/13/2023
Section Cited
HSC
1569.312(a)
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Basic services requirements.
Every facility required to be licensed under this chapter shall provide at least the following basic services:
(a) Care and supervision as defined in Section 1569.2.
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Facility is already closed.
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This requirement is not met based on evidence by interview, and record review. The licensee did not provide Care and supervision to R1 which resulted to resident being severely burned which posed a potential health, safety or personal rights risk to persons in care.
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Type A
07/13/2023
Section Cited
HSC
1569.312(e)
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Basic services requirements
(e) Monitoring the activities of the residents while they are under the supervision of the facility to ensure their general health, safety, and well-being.
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Facility is already closed.
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This requirement is not met based on evidence by interview, and record review. The licensee did not monitor R1 and R1 was able to leave facility unassisted on more than once which posed a potential health, safety, or personal rights risk to persons in care.
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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: Chinwe NwogeneTELEPHONE: (951) 202-2066
LICENSING EVALUATOR SIGNATURE:

DATE: 07/12/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/12/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 18-AS-20201020162344
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: A B CARING SENIOR LIVING
FACILITY NUMBER: 331800058
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/12/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/21/2023
Section Cited
CCR
87211(a)(1)(d)
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Reporting Requirements;
(D) Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident.
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Facility is already closed.
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This requirement is not met based on evidence by interview, and record review. The licensee did not comply by not reporting R1 wandered from the facility without staff supervision department which posed a potential health, safety, or personal rights risk to persons in care.
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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: Chinwe NwogeneTELEPHONE: (951) 202-2066
LICENSING EVALUATOR SIGNATURE:

DATE: 07/12/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/12/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 4