331800083-12-12-2023-18-AS-JDHS-CYRTRW-20231222135811

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 331800083
Report Date: 12/12/2023
Date Signed: 12/12/2023 02:28:06 PM

Unsubstantiated

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
09/24/2020 and conducted by Evaluator Javina George

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20200924141733

FACILITY NAME:	RENAISSANCE VILLAGE MURRIETA		FACILITY NUMBER:	331800083
ADMINISTRATOR:	BRIAN TAUBE		FACILITY TYPE:	740
ADDRESS:	24271 JACKSON AVENUE		TELEPHONE:	(951) 319-8243
CITY:	MURRIETA	STATE: CA	ZIP CODE:	92562
CAPACITY:	166	CENSUS: 86	DATE:	12/12/2023
		UNANNOUNCED	TIME BEGAN:	01:51 PM
MET WITH:	Brian Taube, Jeanne Orona, Executive Director's		TIME COMPLETED:	02:50 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff falsified resident records

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Javina George made an unannounced visit to the facility to deliver findings for the allegation noted above. LPA met with Executive Director's Brian Taube and Jeanne Orona and explained the purpose of the visit and the elements of the allegation. The allegation was investigated, the investigation consisted of observations, interviews and records review.

On 09/24/20 community care licensing received a complaint alleging that the facility falsified resident records. Resident#1 (R1) was admitted to the facility on 02/06/17. Upon admission R1 was diagnosed with Parkinson’s disease. On 09/07/20 R1 was sent at the emergency room due to swelling in their lower extremities. Per the emergency room report the patient history was provided by both the patient and facility staff. The patient history notes that patient history is limited due to dementia. LPA conducted a review of multiple Physician’s reports, Needs and Services plans and resident level of care assessments, where resident is noted as being a level 1, as well as being independent. The documentation reviewed

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Jazmond D Harris	TELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Javina George	TELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:	DATE: 12/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2023

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 2

Control Number 18-AS-20200924141733

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: RENAISSANCE VILLAGE MURRIETA	FACILITY NUMBER: 331800083
	VISIT DATE: 12/12/2023

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

was completed by the facility staff, and R1’s primary care physician dating back to February 2016, with the most recent being completed on 10/19/20. There is nothing noted confirming R1 to have a diagnosis
of dementia. Additionally, LPA observed a copy of the fax cover letter sent by the facility Wellness Director that was requesting clarification of the dementia diagnosis for R1.

A further records review revealed R1’s primary care physician provided a response on a medical script stating that R1 was never diagnosed with dementia, however stated that that R1 had a mild cognitive impairment due to their age. Due to the medical history being provided by both the resident and facility staff, and no documentation to support that staff in fact wrote dementia on R1's paperwork, the allegation is UNSUBSTANTIATED. A finding that the complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation(s) occurred.

An exit interview was conducted and a copy of this report was provided to Executive Director's Brian Taube and Jeanne Orona.

SUPERVISOR'S NAME: Jazmond D Harris	TELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Javina George	TELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:	DATE: 12/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 2