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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331800447
Report Date: 12/15/2023
Date Signed: 12/15/2023 10:41:55 AM

Unsubstantiated


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
, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/18/2022 and conducted by Evaluator Amy Goldenberg
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20220118141100
FACILITY NAME:GRATEFUL HEART HOME CARE INCFACILITY NUMBER:
331800447
ADMINISTRATOR:UY, CHARMAINEFACILITY TYPE:
740
ADDRESS:14223 POINTER LOOPTELEPHONE:
(951) 427-1800
CITY:EASTVALESTATE: CAZIP CODE:
92880
CAPACITY:6CENSUS: 6DATE:
12/15/2023
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Linda Tatofi, CaregiverTIME COMPLETED:
10:30 AM
ALLEGATION(S):
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-Neglect/lack of care and supervision resulted in the questionable death of the resident.
-Neglect/lack of care and supervision resulted in the resident sustaining multiple unexplained injuries while in care.
INVESTIGATION FINDINGS:
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This unannounced visit by Amy Goldenberg, Licensing Program Analyst (LPA), is being conducted to conclude this agency’s investigation into the complaint allegations mentioned above.

During the course of the investigation, interviews were conducted with staff, a review of resident records was completed, and copies of pertinent documents obtained. Evidence collected pertaining to R1 included subpoenaed records from Vision Health and Hospice Care and Corona Regional Medical Center, review of the facility record on file with this agency, and of the record maintained by Grateful Heart Home Care for R1. Review of diaper change logs, narrative charting logs, Corona Regional Medical Center wound care report and emergency room records were reviewed. Additional investigation included text message correspondence between the reporting party and the facility staff.

Investigation revealed the following:

On 11/15/2021 R1 went to the hospital diagnosed with septic shock and severe pneumonia.(take out red) R1 died 4 days later at Coronal Regional Medical Center.

Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Amy GoldenbergTELEPHONE: (951) 201-3990
LICENSING EVALUATOR SIGNATURE:

DATE: 12/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2023
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-20220118141100
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
, CA 92507
FACILITY NAME: GRATEFUL HEART HOME CARE INC
FACILITY NUMBER: 331800447
VISIT DATE: 12/15/2023
NARRATIVE
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It is alleged that the care provided to R1 resulted in their death. R1 was transported to the Emergency Department on 11/15/2021. She was admitted to the hospital on 11/16/2021. R1 passed away on 11/19/2021. The Coroner did not investigate her death. It is alleged that neglect/lack of care and supervision resulted in R1 sustaining multiple unexplained injuries while in care. R1 suffered an unwitnessed fall on 10/14/2021 and sustained an injury to their forehead. Facility staff were present in the room at the time of the fall but did not witness the fall. First aid was rendered but the facility staff did not seek medical attention for the head injury. Head injury is not listed as a cause of death. R1 did not have a history of falls at the facility and did not have any order for postural support while seated. R1 had a medical history of irregular bowl movement and it is not uncommon for R1 to go 3 to 4 days without a bowel movement. 911 was called on 11/15/2021. The facility staff report they did not observe any signs of immediate danger on 11/14/2021.

We have found the complaint allegations are unsubstantiated. Although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. A copy of this report is being reviewed with and furnished to the facility representative.
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Amy GoldenbergTELEPHONE: (951) 201-3990
LICENSING EVALUATOR SIGNATURE:

DATE: 12/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2023
LIC9099 (FAS) - (06/04)
Page: 2 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
, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/18/2022 and conducted by Evaluator Amy Goldenberg
COMPLAINT CONTROL NUMBER: 18-AS-20220118141100

FACILITY NAME:GRATEFUL HEART HOME CARE INCFACILITY NUMBER:
331800447
ADMINISTRATOR:UY, CHARMAINEFACILITY TYPE:
740
ADDRESS:14223 POINTER LOOPTELEPHONE:
(951) 427-1800
CITY:EASTVALESTATE: CAZIP CODE:
92880
CAPACITY:6CENSUS: 6DATE:
12/15/2023
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Linda Tatofi, CaregiverTIME COMPLETED:
10:30 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Neglect/lack of care and supervision resulted in the facility failing to seek timely medical attention.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
This unannounced visit by Amy Goldenberg, Licensing Program Analyst (LPA), is being conducted to conclude this agency’s investigation into the complaint allegations mentioned above.

During the course of the investigation, interviews were conducted with staff, a review of resident records was completed, and copies of pertinent documents obtained. Evidence collected pertaining to R1 included subpoenaed records from Vision Health and Hospice Care and Corona Regional Medical Center, review of the facility record on file with this agency, and of the record maintained by Grateful Heart Home Care for R1. Review of diaper change logs, narrative charting logs, Corona Regional Medical Center wound care report and emergency room records were reviewed.

Investigation revealed the following:

It is alleged that the facility staff did not seek timely medical attention.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Amy GoldenbergTELEPHONE: (951) 201-3990
LICENSING EVALUATOR SIGNATURE:

DATE: 12/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 18-AS-20220118141100
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
, CA 92507
FACILITY NAME: GRATEFUL HEART HOME CARE INC
FACILITY NUMBER: 331800447
VISIT DATE: 12/15/2023
NARRATIVE
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 R1 suffered an unwitnessed fall on 10/21/2021 and sustained an injury to her for head. Staff were present in the room but did not witness the fall. The facility policy for an unwitnessed fall is to call 911. The facility staff did not call for emergency medical services.

We have substantiated the complaint allegation as valid and that a violation has occurred based on the preponderance of available evidence. A copy of this report along with appeal rights are being reviewed with and furnished to the facility representative. Please see LIC 9099D.
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Amy GoldenbergTELEPHONE: (951) 201-3990
LICENSING EVALUATOR SIGNATURE:

DATE: 12/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 18-AS-20220118141100
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
, CA 92507

FACILITY NAME: GRATEFUL HEART HOME CARE INC
FACILITY NUMBER: 331800447
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/15/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/16/2023
Section Cited
CCR
87468.2(a)(8)
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To be free from neglect, financial exploitation, involuntary seclusion, punishment, humiliation, intimidation, and verbal, mental, physical, or sexual abuse. The facility did not meet this requirement
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Licensee to conduct staff training on facility policy, personal rights, and when to call for medical assessment. Statement of understanding from administrator and Licensee on regulation section cited.
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as evidenced by facility staff failing to seek immediate medical treatment by calling 911 for R1’s head injury from an unwitnessed fall on 10/21/2021. This poses a risk to the health and safety of residents in care.
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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: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Amy GoldenbergTELEPHONE: (951) 201-3990
LICENSING EVALUATOR SIGNATURE:

DATE: 12/15/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5