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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331880566
Report Date: 04/28/2021
Date Signed: 04/28/2021 02:43:44 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
03/15/2021 and conducted by Evaluator Deborah Mullen
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20210315132120
FACILITY NAME:FIRST CHOICE SENIOR LIVINGFACILITY NUMBER:
331880566
ADMINISTRATOR:RECINTO, MONTANO OFACILITY TYPE:
740
ADDRESS:34796 MYOPORUM LNTELEPHONE:
(951) 599-4305
CITY:MURRIETASTATE: CAZIP CODE:
92563
CAPACITY:6CENSUS: 5DATE:
04/28/2021
UNANNOUNCEDTIME BEGAN:
12:50 PM
MET WITH:Montana Recinto, LicenseeTIME COMPLETED:
01:30 PM
ALLEGATION(S):
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Resident eviction not in compliance with regulations
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Deborah Mullen contacted an unannounced visit to deliver the findings of the above allegation. LPA was granted entry by Daisy Malang, Caregiver. LPA conducted a health and safety check of the facility. The investigation included interviews with staff and other witnesses and a review of facility documentation.

Allegation #1 - resident eviction was not in compliance with regulations. Information provided by witness interviews revealed the licensee had advised for resident 1 (R1) to go on hospice and that if R1 did not go on hospice that he/she would have one week to move out of the facility. The licensee confirmed that he had told R1’s family that if R1 was not going on hospice then he would have one week to be removed from the facility. Licensee stated R1 was not provided an eviction notice as required by Title 22 regulations.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 836-2784
LICENSING EVALUATOR NAME: Deborah MullenTELEPHONE: (951) 212-0616
LICENSING EVALUATOR SIGNATURE:

DATE: 04/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2021
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 4
Control Number 18-AS-20210315132120
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: FIRST CHOICE SENIOR LIVING
FACILITY NUMBER: 331880566
VISIT DATE: 04/28/2021
NARRATIVE
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Based upon the investigation the allegation the preponderance of evidence standard has been met. Therefore, the allegation is substantiated, and a citation is being issued on the attached LIC 9099D.

An exit interview was conducted, and this report was reviewed with licensee. A copy of the report was emailed to licensee for his review and signature.
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 836-2784
LICENSING EVALUATOR NAME: Deborah MullenTELEPHONE: (951) 212-0616
LICENSING EVALUATOR SIGNATURE:

DATE: 04/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 4
Control Number 18-AS-20210315132120
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: FIRST CHOICE SENIOR LIVING
FACILITY NUMBER: 331880566
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/28/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/07/2021
Section Cited
CCR
87724(a)
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Eviction Procedures: The licensee may evict a resident for one or more of the reasons listed in Section 87224(a)(1) through (5). Thirty (30) days written notice to the resident is required except as otherwise specified in paragraph (5).
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Licensee will review Section 87724 and submit a self-certification of review and understanding of the regulation. This will be submitted to the department by 5/7/21.
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 This requirement was not being met as evidenced by: Licensee confirmed that R1 was given 1 week to relocate if he/she was not going to be admitted to hospice. This posed a potential health and safety risk to resident 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: Karen ClemonsTELEPHONE: (951) 836-2784
LICENSING EVALUATOR NAME: Deborah MullenTELEPHONE: (951) 212-0616
LICENSING EVALUATOR SIGNATURE:

DATE: 04/28/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 4
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
03/15/2021 and conducted by Evaluator Deborah Mullen
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20210315132120

FACILITY NAME:FIRST CHOICE SENIOR LIVINGFACILITY NUMBER:
331880566
ADMINISTRATOR:RECINTO, MONTANO OFACILITY TYPE:
740
ADDRESS:34796 MYOPORUM LNTELEPHONE:
(951) 599-4305
CITY:MURRIETASTATE: CAZIP CODE:
92563
CAPACITY:6CENSUS: 5DATE:
04/28/2021
UNANNOUNCEDTIME BEGAN:
12:50 PM
MET WITH:Montano RecintoTIME COMPLETED:
01:30 PM
ALLEGATION(S):
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Staff have not assisted the resident with medication
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Deborah Mullen contacted an unannounced visit to deliver the findings of the above allegation. LPA was granted entry by Daisy Malang, Caregiver. LPA conducted a health and safety check of the facility. The investigation included interviews with staff and other witnesses and a review of facility documentation.

Allegation #1 - Staff have not assisted the resident with medication. The licensee denied the allegation that resident 1 (R1) was not given his/her medication. The licensee stated R1 was provided his/her medication but did that R1 did not like to take it. Additional information provided was that due to R1s behavior it did not appear he/she was receiving his/her medication.

Based upon the investigation the allegation is unsubstantiated. Although the allegation may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated at this time. An exit interview was conducted, and this report was reviewed with licensee. A copy of the report was emailed to licensee for his review and signature.

Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 836-2784
LICENSING EVALUATOR NAME: Deborah MullenTELEPHONE: (951) 212-0616
LICENSING EVALUATOR SIGNATURE:

DATE: 04/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2021
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 4