331800114-9-29-2021-18-AS-RLAY-C8ZQFF-20211122110753

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 331800114
Report Date: 09/29/2021
Date Signed: 09/29/2021 03:20:02 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
09/24/2021 and conducted by Evaluator Deborah Mullen

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20210924151620

FACILITY NAME:	VINEYARD RANCH AT TEMECULA		FACILITY NUMBER:	331800114
ADMINISTRATOR:	KURT KNAUER		FACILITY TYPE:	740
ADDRESS:	27350 NICOLAS RD		TELEPHONE:	(951) 308-1988
CITY:	TEMECULA	STATE: CA	ZIP CODE:	92591
CAPACITY:	125	CENSUS: 82	DATE:	09/29/2021
		UNANNOUNCED	TIME BEGAN:	11:40 AM
MET WITH:	Kurt Knauer, Executive Director and Tammy Carvajal, Business Manager		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Resident fell due to a lack of supervision

INVESTIGATION FINDINGS:

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

Licensing Program Analyst (LPA) Deborah Mullen conducted an unannounced visit to investigate the above allegation. LPA met with Kurt Knauer, Executive Director and Tammy Carvajal, Business Manager. LPA interviewed staff, reviewed and obtained copies of Resident 1s (R1s) file and attempted to interview R1.

Staff interviews provided information of a recent change in condition of R1. Staff acknowledge R1 has had a couple of recent falls, but attribute that to the change in condition. Staff denied the falls were due to a lack of sufficient staffing. Staff reported the falls to R1s responsible party and to R's doctor and have taken steps to mitigate additional falls. Staff have increased R1s supervision and are assisting R1 with transferring, using the restroom and showering. A review of facility documentation indicate R1 was diagnosed with a Urinary Tract Infection on September 19, 2021 and had a follow up tele-visit with the doctor on September 28, 2021. Based on a review of R1s Resident Appraisal, dated March 30, 2021 and prior to the recent change in condition, R1 only required a stand by assist and did not have a history of falls. Facility staff have continued to work with R1's responsible party and R1s doctor to monitor and address R1s change in condition.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 836-2784
LICENSING EVALUATOR NAME: Deborah Mullen	TELEPHONE: (951) 212-0616
LICENSING EVALUATOR SIGNATURE:	DATE: 09/29/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2021

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 2

Control Number 18-AS-20210924151620

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: VINEYARD RANCH AT TEMECULA	FACILITY NUMBER: 331800114
	VISIT DATE: 09/29/2021

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

Based upon the investigation there is not a preponderance of evidence to prove resident fell due to a lack of supervision, therefore this allegation is found to be unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated at this time. An exit interview was conducted, and a copy of this report was reviewed with and provided to Ms. Carvajal.

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 836-2784
LICENSING EVALUATOR NAME: Deborah Mullen	TELEPHONE: (951) 212-0616
LICENSING EVALUATOR SIGNATURE:	DATE: 09/29/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 2