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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331800103
Report Date: 11/14/2022
Date Signed: 11/14/2022 09:24:49 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
09/07/2021 and conducted by Evaluator Crystal Colvin
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20210907142918
FACILITY NAME:LEGEND GARDENSFACILITY NUMBER:
331800103
ADMINISTRATOR:PENDINGFACILITY TYPE:
740
ADDRESS:73685 CATALINA WAYTELEPHONE:
(760) 773-3115
CITY:PALM DESERTSTATE: CAZIP CODE:
92260
CAPACITY:0CENSUS: 0DATE:
11/14/2022
UNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Staff and designee not available, facility closed 1/6/2022TIME COMPLETED:
09:30 AM
ALLEGATION(S):
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Failure to report resident death
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Crystal Colvin phoned designee Mark Hellickson in an effort to deliver finding of an investigation into the allegations listed above. LPA was unable to make contact with Hellickson and although LPA requested a return call, one was not received.

Regarding allegation "Failure to report resident death": LPA Colvin reviewed the Department’s log for any Special Incident Reports (SIRs) and deaths reported by the facility. LPA Colvin observed that there was only one incident reported by the facility for Resident 1 (R1), which was R1’s fall on December 4, 2020, wherein R1 was transported to the hospital by emergency personnel. This report was received by the department on December 11, 2020, no further reports have been received for R1. R1 passed on January 9, 2021, the facility failed to report this incident as required. LPA Colvin additionally observed that when the Department went out to the facility on September 8, 2021, to obtain records from R1’s file in regard to the complaint, there was no Death Report in R1’s file. Interviews conducted during the investigation confirm that staff were made aware to R1’s passing prior to the Department’s investigation, yet there is no evidence
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Crystal ColvinTELEPHONE: (951) 204-0848
LICENSING EVALUATOR SIGNATURE:

DATE: 11/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2022
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 5
Control Number 18-AS-20210907142918
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: LEGEND GARDENS
FACILITY NUMBER: 331800103
VISIT DATE: 11/14/2022
NARRATIVE
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to show that anyone from the facility contacted the Department to notify of R1’s passing. Therefore, due to the facility’s lack of evidence to confirm that they reported R1’s death, and no reports received by the Department, the allegation “Failure to report resident death” is SUBSTANTIATED.

A finding that the complaint is SUBSTANTIATED means that the allegation(s) is valid because the preponderance of the evidence standard has been met.

An exit interview was not able to be conducted however, a copy of this report along with LIC 811- Confidential Names List was sent via email to designee at m.hellickson@icloud.com.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Crystal ColvinTELEPHONE: (951) 204-0848
LICENSING EVALUATOR SIGNATURE:

DATE: 11/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 5
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
09/07/2021 and conducted by Evaluator Crystal Colvin
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20210907142918

FACILITY NAME:LEGEND GARDENSFACILITY NUMBER:
331800103
ADMINISTRATOR:PENDINGFACILITY TYPE:
740
ADDRESS:73685 CATALINA WAYTELEPHONE:
(760) 773-3115
CITY:PALM DESERTSTATE: CAZIP CODE:
92260
CAPACITY:0CENSUS: DATE:
11/14/2022
UNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Staff and designee not available, facility closed 1/6/2022TIME COMPLETED:
09:30 AM
ALLEGATION(S):
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Lack of care and supervision contributed to resident's death

Failure to properly safeguard resident's property upon death
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Crystal Colvin phoned designee Mark Hellickson in an effort to deliver finding of an investigation into the allegations listed above. LPA was unable to make contact with Hellickson and although LPA requested a return call, one was not received.

Regarding allegation "Lack of care and supervision contributed to resident's death": The Department investigated this allegation through interview of facility staff and review of facility records for Resident 1 (R1) and hospital records for R1. Through record review and interview it was revealed that on December 4, 2020, R1 had an unwitnessed fall at the facility, wherein R1 sustained a head injury. Staff reportedly found R1 and immediately contacted 911 and was subsequently taken to the hospital. R1 was treated until they passed away in the hospital on January 9, 2021, cause of death was noted as blunt force trauma. According to interviews with facility staff, R1 had lived at the facility since 2014, was independent, ambulated with a walker and did not require any additional status checks, apart from the standard two hour check every two hours. During the six years that R1 lived at the facility, only two falls were documented (September 27, 2019 & February 2, 2020).
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Crystal ColvinTELEPHONE: (951) 204-0848
LICENSING EVALUATOR SIGNATURE:

DATE: 11/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 18-AS-20210907142918
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: LEGEND GARDENS
FACILITY NUMBER: 331800103
VISIT DATE: 11/14/2022
NARRATIVE
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R1 was not a fall risk and did not have to have continuous monitoring. R1 resided in the assisted living portion of the facility. R1 was not on hospice or home health care. R1 was re-evaluated by physician on March 6, 2020, after R1’s prior fall, and R1 was determined to be ambulatory with no other concerns. Therefore, due to lack of evidence to suggest that facility staff did not provide the level of care & supervision required by R1, the allegation “Lack of care and supervision contributed to resident's death” is UNSUBSTANTIATED.

Regarding allegation "Failure to properly safeguard resident's property upon death": LPA Colvin reviewed facility records for R1, including the inventory and valuables list completed by residents when they move into the facility, as well as interviews conducted by Department with facility staff. LPA Colvin observed that upon R1’s move into the facility in 2014, R1 had minimal property listed on the form other than a couple of clothing items, shoes, hat, watch, and glasses. The resident’s inventory list was not updated throughout the six years that R1 resided at the facility, and according to interviews with staff, R1 did not receive any supplies or additional funds from family towards the end of R1’s stay at the facility, however, staff members state that they would purchase or provide R1 with additional clothing when needed. Additionally, since no one claimed R1’s remains at the hospital upon passing; R1’s remains were held in storage for six months until they were eventually released to Riverside County Public Administrator. Therefore, due to lack of documentation of R1’s belongings and the amount of time that has passed since R1 passed away, there is not enough evidence to support the allegation, “Failure to properly safeguard resident's property upon death”, which is UNSUBSTANTIATED.

A finding of UNSUBSTANTIATED means although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur.

An exit interview was not able to be conducted however, a copy of this report along with LIC 811- Confidential Names List was sent via email to designee at m.hellickson@icloud.com.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Crystal ColvinTELEPHONE: (951) 204-0848
LICENSING EVALUATOR SIGNATURE:

DATE: 11/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 18-AS-20210907142918
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: LEGEND GARDENS
FACILITY NUMBER: 331800103
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/14/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/15/2022
Section Cited
CCR
87211(a)(1)(A)
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Reporting Requirements: (a) Each licensee shall furnish...such reports..including... (1) A written report shall be submitted...within seven days of the occurrence of any of the events specified...(A) Death of any resident from any cause regardless of where the death occurred... This requirement was not met by:
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Designee was not available for plan of correction. Facility was closed January 6, 2022
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Based on record review, the Licensee did not comply with the above regulation with at least one resident. LPA Colvin observed that R1 passed away on 1/9/21, but as of 9/8/21, the Department had not received any notification from the facility of R1's passing. This was an immediate health risk for R1.
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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: Crystal ColvinTELEPHONE: (951) 204-0848
LICENSING EVALUATOR SIGNATURE:

DATE: 11/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 5