331800167-9-30-2020-18-AS-EMAN-BTYLXD-20201001090834

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 331800167
Report Date: 08/25/2020
Date Signed: 09/30/2020 02:24:10 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
04/15/2020 and conducted by Evaluator Stephanie Williams

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20200415161748

FACILITY NAME:	DULCE VILLA I		FACILITY NUMBER:	331800167
ADMINISTRATOR:	MODY, NIKUL		FACILITY TYPE:	740
ADDRESS:	66147 S AGUA DULCE DR		TELEPHONE:	(760) 251-7842
CITY:	DESERT HOT SPRINGS	STATE: CA	ZIP CODE:	92240
CAPACITY:	6	CENSUS: 5	DATE:	08/25/2020
		UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Trupti Mody		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

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Facility staff did not provide medical information to resident's medical staff
Facility staff did not provide timely transportation for resident's medical appointment

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Stephanie Williams contacted the facility to deliver findings for the above allegations via telephone due to the COVID-19 pandemic. LPA identified herself and discussed the purpose of the call with Licensee, Trupti Mody. The investigation consisted of interviews with relevant parties.

In regards to allegation #1, LPA interviewed Staff #1 (S1) who stated that Resident #1 (R1) was independent and able to communicate properly. S1 could not recall if medical information was provided to the staff at optometry office. LPA was unable to locate Resident #1 (R1) to get a statement.

In regards to allegation #2, LPA interviewed Staff #1 (S1) who stated that R1 did not communicate with the facility staff that R1 would be going to an appointment. S1 stated that R1 makes their own appointments and arranges their own transportation. According to S1, R1 stated that they were able to make it to their next appointment on time and there were no issues with transporation.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 248-0337
LICENSING EVALUATOR NAME: Stephanie Williams	TELEPHONE: (951) 248-0317
LICENSING EVALUATOR SIGNATURE:	DATE: 08/25/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2020

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

LIC9099 (FAS) - (06/04)

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Control Number 18-AS-20200415161748

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: DULCE VILLA I	FACILITY NUMBER: 331800167
	VISIT DATE: 08/25/2020

NARRATIVE

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Based on evidence obtained during today’s visit, LPA has determined that the above allegations are UNSUBSTANTIATED; meaning that although the allegations 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 this report was discussed with Mody via telephone. A copy of this report was provided to Mody via email.

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 248-0337
LICENSING EVALUATOR NAME: Stephanie Williams	TELEPHONE: (951) 248-0317
LICENSING EVALUATOR SIGNATURE:	DATE: 08/25/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2020

LIC9099 (FAS) - (06/04)

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