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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331880545
Report Date: 08/19/2022
Date Signed: 08/19/2022 03:20:57 PM

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
08/17/2022 and conducted by Evaluator Crystal Colvin
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20220817154457
FACILITY NAME:MAC'S HOME #1FACILITY NUMBER:
331880545
ADMINISTRATOR:PETERS, STEPHANIEFACILITY TYPE:
735
ADDRESS:887 ARIA RDTELEPHONE:
(909) 910-9114
CITY:HEMETSTATE: CAZIP CODE:
92543
CAPACITY:4CENSUS: 4DATE:
08/19/2022
UNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Junita Sanchez - AdministratorTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Facility failed to assist client in seeking medical care

Lack of sufficient staffing

Facility has threatened to evict client as retaliation
INVESTIGATION FINDINGS:
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On today's date, Licensing Program Analyst (LPA) Crystal Colvin arrived at the facility unannounced for the purpose of initiating an investigation with the above allegation. LPA Colvin met with Administrator Junita Sanchez. Below is a summary of the findings of the investigation:

Regarding allegation "Facility failed to assist client in seeking medical care": LPA Colvin conducted interviews with staff, residents, and other relative parties in regards to resident (R1) requesting to go to the hospital and be tested for COVID-19 due to recent exposure. LPA Colvin additionally reviewed facility documentation from R1's file and observed that on 7/31/22 & 8/3/22 R1 was tested at the facility and was negative. LPA Colvin additionally observed a staff note from 7/30/22 stating that R1 was "insisting on going to the doctor...due to being anxious about being contagious". Interviews conducted by LPA Colvin confirmed that R1 was requesting to go to the hospital and instead of staff testing R1 with a COVID-19 home test that day or aiding in R1 getting tested elsewhere or seeking medical attention, facility staff disuaded R1 from going to the hospital, and advised R1 that if they did really want to go to call 911. No further assistance provided 7/30/22.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Crystal Colvin
LICENSING EVALUATOR SIGNATURE:

DATE: 08/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2022
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 7
Control Number 18-AS-20220817154457
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: MAC'S HOME #1
FACILITY NUMBER: 331880545
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/19/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/22/2022
Section Cited
CCR
80072(a)(3)
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Personal Rights : (a) Except for children’s residential facilities, each client shall have personal rights which include, but are not limited to, the following: (3) To be free from..unusual punishment,....intimidation,... threat, mental abuse, or other actions of a punitive nature... This was not met by:
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 Licensee agrees to review Title 22 Regulation Section 80068.5 regarding Eviction Procedures and what qualifies as basis for eviction. Administrator and Licensee to additionally be re-trained on Personal Rights of Residents & Personal RIghts or Persons with Developmental Disabilities. Training is not to be
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Based on interviews conducted, the Licensee did not comply with the above regulation with 1 of 4 residents. Licensee Stephanie Peters and Administrator Juanita Sanchez both made threats that R1 would be provided eviction notice due to R1's family filing complaints. This was an immediate personal rights violation.
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conducted or administered by Licensee(s) due to Licensee Stephanie Peters to be trained for correction plan as well. Proof of training to be submitted to LPA Colvin by Plan of Correction date of 8/22/22.
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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.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Crystal Colvin
LICENSING EVALUATOR SIGNATURE:

DATE: 08/19/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 7
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
08/17/2022 and conducted by Evaluator Crystal Colvin
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20220817154457

FACILITY NAME:MAC'S HOME #1FACILITY NUMBER:
331880545
ADMINISTRATOR:PETERS, STEPHANIEFACILITY TYPE:
735
ADDRESS:887 ARIA RDTELEPHONE:
(909) 910-9114
CITY:HEMETSTATE: CAZIP CODE:
92543
CAPACITY:4CENSUS: 4DATE:
08/19/2022
UNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Junita Sanchez - AdministratorTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Facility violated client's personal rights
INVESTIGATION FINDINGS:
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On today's date, Licensing Program Analyst (LPA) Crystal Colvin arrived at the facility unannounced for the purpose of initiating an investigation with the above allegation. LPA Colvin met with Administrator Junita Sanchez. Below is a summary of the findings of the investigation:

Regarding allegation "Facility violated client's personal rights": LPA Colvin investigated the allegation in relation to resident (R1) not being allotted privacy in telephone calls. LPA Colvin conducted interviews with staff, residents, and other persons with possible knowledge on the allegation. Interviews conducted primarily indicated that R1 sometimes talks on the phone in common areas and will talk loudly, or will talk to staff after phone calls and volunteer information or summary of what was discussed. LPA Colvin was unable to obtain corroborating evidence to suggest that R1's telephone calls are listened to by staff, unless specifically requested by R1 to have staff on the phone with them or near them for support. Therefore, based on interviews and lack of additional evidence, the allegation "Facility violated client's personal rights" is UNSUBSTANTIATED.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Crystal Colvin
LICENSING EVALUATOR SIGNATURE:

DATE: 08/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 18-AS-20220817154457
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: MAC'S HOME #1
FACILITY NUMBER: 331880545
VISIT DATE: 08/19/2022
NARRATIVE
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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 conducted with Administrator Juanita Sanchez and a copy of this report was provided.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Crystal Colvin
LICENSING EVALUATOR SIGNATURE:

DATE: 08/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2022
LIC9099 (FAS) - (06/04)
Page: 7 of 7
Control Number 18-AS-20220817154457
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: MAC'S HOME #1
FACILITY NUMBER: 331880545
VISIT DATE: 08/19/2022
NARRATIVE
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According to interviews conducted, R1 reported to staff on 7/30/22 that they had symptoms and overall did not feel well, and that was part of the basis of wanting to go to the hospital. Staff did not assist R1 with their medical concerns (such as by testing them that day or offering to transport) and instead attempted to convince R1 that they did not need medical attention. Facility staff additionally told R1 that if R1 went to the hospital that they may need to quarantine for 14 days upon return to the facility. Therefore, based on record review and interviews conducted, the allegation "Facility failed to assist client in seeking medical care" is SUBSTANTIATED.

Regarding allegation "Lack of sufficient staffing": LPA Colvin conducted interviews regarding R1 being transported by facility staff to the grocery store and Licensee's other location (#331880966) in Riverside. LPA Colvin confirmed that while other residents are at their Day Programs the Administrator has taken R1 to run errands for the facility, such as grocery shopping or picking up paperwork (Riverside). Administrator Juanita Sanchez stated to LPA Colvin that R1 is happy to go out into the community with her, and that she asks R1 if she wants to go with her. However, during these outings there have been no other staff at the facility to be able to supervise R1 or other residents, should they wish to remain behind. Therefore, based on interviews and record review, the allegation "Lack of sufficient staffing" is SUBSTANTIATED.

Regarding allegation "Facility has threatened to evict client as retaliation": LPA Colvin conducted interviews with staff, residents, and other relative parties in regards to R1's placement at the facility being threatened due to R1's mother stating they would/have filed complaints against the facility. Multiple persons interviewed confirmed that both Licensee Stephanie Peters and Administrator Juanita Sanchez stated during a meeting with R1, facility staff, and Inland Regional Center (IRC) that R1 would be provided with a 30-day eviction notice if R1's mother kept reporting the facility. Additionally, during an interview with Licensee Stephanie Peters for a different complaint (#18-AS-20200813155403) regarding R1, the Licensee stated that due to R1's mother calling in complaints that she was going to provide R1 with a 30-day notice. While no 30-day notice has been issued to R1 at this time, there is sufficient evidence to support the allegation that R1 has threatened eviction of R1. Therefore, based on interviews conducted, the allegation "Facility has threatened to evict client as retaliation" 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.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Crystal Colvin
LICENSING EVALUATOR SIGNATURE:

DATE: 08/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 18-AS-20220817154457
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: MAC'S HOME #1
FACILITY NUMBER: 331880545
VISIT DATE: 08/19/2022
NARRATIVE
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Due to observations made by LPA Colvin, the facility was cited and deficiencies noted on LIC 9099 D. An exit interview was conducted where this report and appeal rights were discussed. A copy this report, LIC 9099D, and appeal rights were provided to Administrator Juanita Sanchez during the exit interview.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Crystal Colvin
LICENSING EVALUATOR SIGNATURE:

DATE: 08/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 7
Control Number 18-AS-20220817154457
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: MAC'S HOME #1
FACILITY NUMBER: 331880545
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/19/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/22/2022
Section Cited
CCR
80072(a)(9)
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Personal Rights : (a) Except for children’s residential facilities, each client shall have personal rights which include, but are not limited to, the following: (9) To receive or reject medical care, or health-related services... This requirement was not met as evidenced by:
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Licensee & Administrator agree to review Title 22 Regulations Section for Personal Rights and submit Statement of Understanding regarding said rights, along with Self-Certification that section was reviewed. Plan of Correction due date 8/22/22.
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Based on interviews and record review, the Licensee did not comply with the regulation with 1 of 4 residents. On 7/30/22, R1 was requesting to go to the hospital and/or be tested for COVID-19. Facility staff disuaded R1 and did not test until 7/31/22. This was an immedaite personal rights violation of R1.
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Type B
09/02/2022
Section Cited
CCR
80065(a)
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Personnel Requirements: (a) Facility personnel shall be competent to provide the services necessary to meet individual client needs and shall, at all times, be employed in numbers necessary to meet such needs. This requirement was not met as evidenced by:
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Licensee agrees to have a facility meeting with residents informing them that they have the right to decline running facility errands/going on outings, and that they can remain at facility & staff to provide supervision. Licensee to provide summary of facility meeting with participants signatures and date by Plan of
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Based on interviews and record review, the Licensee did not comply with the above regulation. R1 has been subject to running facility errands with Administrator as there is no other staff available at facility to provide supervision to R1 during this time. This is a potential personal rights violation of R1.
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Corrections date of 9/2/22.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Crystal Colvin
LICENSING EVALUATOR SIGNATURE:

DATE: 08/19/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 7