331800114-11-6-2023-18-AS-RSTS-D3XUH2-20240402153512

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 331800114
Report Date: 11/06/2023
Date Signed: 11/06/2023 03:43:38 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
06/01/2020 and conducted by Evaluator Jesse Gardner

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20200601103146

FACILITY NAME:	VINEYARD RANCH AT TEMECULA		FACILITY NUMBER:	331800114
ADMINISTRATOR:	AREVALO, DONNA		FACILITY TYPE:	740
ADDRESS:	27350 NICOLAS RD		TELEPHONE:	(951) 308-1988
CITY:	TEMECULA	STATE: CA	ZIP CODE:	92591
CAPACITY:	0	CENSUS: 95	DATE:	11/06/2023
		UNANNOUNCED	TIME BEGAN:	02:55 PM
MET WITH:	Business Office Manager Jonah Villegas		TIME COMPLETED:	03:55 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff did not seek medical attention in a timely manner.

INVESTIGATION FINDINGS:

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

Licensing Program Analyst (LPA) Jesse Gardner made an unannounced visit to deliver the findings of the above allegation. LPA met with Business Office Manager Jonah Villegas. The Department investigation included interviews with facility staff, medical professionals, and a review of Resident One’s (R1’s) medical and facility records.

Regarding the allegation that staff did not seek medical attention in a timely manner, it was reported that staff did not seek medical attention for resident for approximately 48 hours after noticing the change of condition.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Joel Esquivel	TELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Jesse Gardner	TELEPHONE: (951) 205-2683
LICENSING EVALUATOR SIGNATURE:	DATE: 11/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2023

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 5

Control Number 18-AS-20200601103146

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: VINEYARD RANCH AT TEMECULA	FACILITY NUMBER: 331800114
	VISIT DATE: 11/06/2023

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

The Department conducted a review of the Narrative Charting document for dates 04/29/2020 and 04/30/2020. The charting notes were entered by various staff throughout the two days. The document revealed the following for the date 04/29/2020: one staff noted R1 was not eating and appeared to be in pain, noting R1’s eyes were closed all day. Staff gave R1 Tylenol at 5:30pm, and 9:30pm and continued to monitor. A different staff noted at approximately 10:30am, R1 was seen by staff sitting at the dining table wiggling their body and clinching their teeth together. Staff further noted R1 had their hands in tight fists holding them down on the table. R1 was seen by staff with their eyes closed tightly, and their forehead was wrinkled. At this time, staff gave R1 Tylenol, and called staff nurse, S5. While waiting for S5, staff laid R1 down in bed to see if it would provide relief. S5 arrived and told staff to continue to monitor R1 that R1 might be having a medical episode.

The Narrative Charting document for the date of 04/30/2020 revealed the following: one staff noted R1 made a whining noise and continued to be restless throughout the night. The staff noted they reported the issue to S5, and S5 instructed them to give R1 Tylenol every 4 hours, and to continue monitoring. A different staff noted at about 11:00am R1’s family would set up video chat and R1 appeared to still be in pain.

Interviews with staff corroborated the entries made on the charting document. At 4:30pm on 04/30/2020 a 911 call was made and R1 was transported to the hospital.

R1’s doctor was interviewed. The doctor indicated they were R1’s primary care physician. The doctor reported they were not contacted to schedule a Tele-visit by the facility or R1’s family.

Based on the investigation, the allegation that staff did not seek medical attention in a timely manner is Substantiated. Interviews with facility staff revealed staff waited about 48 hours before calling 911.

A Substantiated finding means that the allegation is valid because the preponderance of evidence standard has been met. In addition, this violation posed an immediate Health and Safety risk to resident(s) in care. An exit interview was conducted, and a copy of this report was reviewed with and provided to Ms. Villegas along with LIC9099D, LIC811, and Appeal Rights.

SUPERVISOR'S NAME: Rikesha Stamps	TELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Jesse Gardner	TELEPHONE: (951) 205-2683
LICENSING EVALUATOR SIGNATURE:	DATE: 11/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 5

Control Number 18-AS-20200601103146

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: VINEYARD RANCH AT TEMECULA	FACILITY NUMBER: 331800114
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/06/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 11/07/2023 Section Cited CCR 87465(a)(1)	1 2 3 4 5 6 7	Incidental Medical and Dental Care: (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following:(1) The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents.	1 2 3 4 5 6 7	Licensee agrees to provide LPA a plan to conduct in-service training to all staff by 5pm and provide proof to LPA by the POC date.
	8 9 10 11 12 13 14	This requirement was not being met as evidenced by: On 4/29/20 at approximately 1030 R1 was observed to have a change in condition. Facility staff failed to seek medical attention until the afternoon of 4/30/21. This posed an immediate health and safety risk to resident in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Rikesha Stamps	TELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Jesse Gardner	TELEPHONE: (951) 205-2683
LICENSING EVALUATOR SIGNATURE:	DATE: 11/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 5

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
06/01/2020 and conducted by Evaluator Jesse Gardner

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20200601103146

FACILITY NAME:	VINEYARD RANCH AT TEMECULA		FACILITY NUMBER:	331800114
ADMINISTRATOR:	AREVALO, DONNA		FACILITY TYPE:	740
ADDRESS:	27350 NICOLAS RD		TELEPHONE:	(951) 308-1988
CITY:	TEMECULA	STATE: CA	ZIP CODE:	92591
CAPACITY:	0	CENSUS: 95	DATE:	11/06/2023
		UNANNOUNCED	TIME BEGAN:	02:55 PM
MET WITH:	Jonah Villegas, Business Office Manager		TIME COMPLETED:	03:55 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Resident passed away as a result of neglect and/or lack of supervision
Inadequate staffing to meet resident's needs

INVESTIGATION FINDINGS:

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

Licensing Program Analyst (LPA) Jesse Gardner delivered the findings of the above allegation. LPA met with Business Jonah Villegas The Department investigation included interviews with facility staff, a medical professional, and a review of Resident One’s (R1’s) medical and facility records.

It was alleged R1 died as a result of neglect and/or lack of supervision. R1 passed away on 05/01/2020. Interviews and review of facility documents as well as medical documents did not corroborate or refute the allegation. Information obtained revealed R1 was admitted to the hospital on 04/30/2020. Information obtained also revealed R1’s health was declining.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Rikesha Stamps	TELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Jesse Gardner	TELEPHONE: (951) 205-2683
LICENSING EVALUATOR SIGNATURE:	DATE: 11/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 18-AS-20200601103146

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: VINEYARD RANCH AT TEMECULA	FACILITY NUMBER: 331800114
	VISIT DATE: 11/06/2023

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

Based on the investigation, the allegation that resident passed away as a result of neglect and/or lack of supervision cannot be corroborated nor refuted, therefore the allegation is unsubstantiated at this time.

It was alleged that the facility did not have enough staff to care for the residents’ needs. Interview with the Executive Director (ED) affirmed that there were plenty of caregivers to provide for the needs of residents. The Department attempted a review of records but was not successful to verify statements provided by the ED. Separate staff interview paralleled ED’s statement that staff would consistently work overtime to cover the shifts to provide for the resident’s needs.

It was also alleged that due to staff neglect, a resident had jumped out of a window and landed on a staff member’s car. Allegedly, that same resident had multiple falls in the facility which was a result of staff hours being cut. Staff interviews revealed that they had no recollection of the events that were alleged. Additionally, the Department conducted an internal record review and found no evidence to investigate further. Due to not enough evidence obtained based on record retention, this allegation is Unsubstantiated.
A finding of UNSUBSTANTIATED means that 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 conducted where a copy of this report was provided.

A finding of UNSUBSTANTIATED means that 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 conducted, and a copy of this report was reviewed with and provided to Ms. Villegas.

This is an amended copy of the original report dated 11/6/2023.

SUPERVISOR'S NAME: Rikesha Stamps	TELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Jesse Gardner	TELEPHONE: (951) 205-2683
LICENSING EVALUATOR SIGNATURE:	DATE: 12/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2023

LIC9099 (FAS) - (06/04)

Page: 5 of 5