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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331800065
Report Date: 10/08/2020
Date Signed: 10/08/2020 03:28:33 PM



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
10/02/2020 and conducted by Evaluator Deborah Mullen
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20201002115326
FACILITY NAME:SACRED HEART-EDGEMONTFACILITY NUMBER:
331800065
ADMINISTRATOR:MACIAS, EVELYNFACILITY TYPE:
740
ADDRESS:37212 EDGEMONT DRIVETELEPHONE:
(949) 257-8344
CITY:MURRIETASTATE: CAZIP CODE:
92563
CAPACITY:6CENSUS: 7DATE:
10/08/2020
UNANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:Bruce Smerker, LicenseeTIME COMPLETED:
01:00 PM
ALLEGATION(S):
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Facility is overcapacity
INVESTIGATION FINDINGS:
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Licensing Program Analyst's (LPA's) Deborah Mullen and David Cuevas initiated the investigation of the above allegations. LPA's met with Samantha Moreno Cabrales, Caregiver, initially. Licensee Bruce Smerker arrived to the facility and met with LPA's. During the visit LPA's did a health and safety inspection of the home, interviewed 2 staff and reviewed client files. The facility is licensed for a capacity of 6, however LPA's observed there to be 7 residents in care. The licensee stated the resident was moved from their other facility to this facility earlier this week.

Based upon LPA observations the allegation that the facility is operating over capacity is substantiated and a citation is being issued. An exit interview was conducted and a copy of this report, along with LIC 811 (Confidential Names List) and appeal rights were reviewed with and provided to Mr. Smerker .
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 836-2784
LICENSING EVALUATOR NAME: Deborah MullenTELEPHONE: (951) 212-0616
LICENSING EVALUATOR SIGNATURE:

DATE: 10/08/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2020
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-20201002115326
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: SACRED HEART-EDGEMONT
FACILITY NUMBER: 331800065
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/08/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/09/2020
Section Cited
CCR
87204(a)
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Limitations - Capacity and Ambulatory Status: (a) A licensee shall not operate a facility beyond the conditions and limitations specified on the license, including specification of the maximum number of persons who may receive services at any one time. An exception may be made in the case of catastrophic emergency when the licensing agency may make temporary exceptions to the approved capacity.
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Per the licensee resident (R1) will be relocated to Sacred Hearts Skyview on 10/8/20. Licensee spoke with son on 10/8/20 while he was at the facility and he agreed to moving her back to the Stoyview home.
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This requirement was not being met as evidenced by: The facility is licensed for a capacity of 6 residents, however during the inspection on 10/8/20, 7 residents were observed to be residing at the home. This poses an immediate health and safety risk to residents 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: Karen ClemonsTELEPHONE: (951) 836-2784
LICENSING EVALUATOR NAME: Deborah MullenTELEPHONE: (951) 212-0616
LICENSING EVALUATOR SIGNATURE:

DATE: 10/08/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2020
LIC9099 (FAS) - (06/04)
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