331880585-4-24-2023-18-AS-NBRN-CRBMQW-20230428094922

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 331880585
Report Date: 04/09/2023
Date Signed: 04/24/2023 02:39:34 PM

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
RIVERSIDE, CA 92507

This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/23/2020 and conducted by Evaluator Anna Bueno

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20200723084004

FACILITY NAME:	COOL MEADOW CARE		FACILITY NUMBER:	331880585
ADMINISTRATOR:	DHAHBI, NADA		FACILITY TYPE:	740
ADDRESS:	29787 COOL MEADOW DR		TELEPHONE:	(951) 246-0214
CITY:	MENIFEE	STATE: CA	ZIP CODE:	92587
CAPACITY:	6	CENSUS: 6	DATE:	04/09/2023
		UNANNOUNCED	TIME BEGAN:	09:37 AM
MET WITH:	John Zhang - Licensee		TIME COMPLETED:	02:43 PM

ALLEGATION(S):

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Facility staff did not assist resident with toileting needs.
Facility staff did not assist resident with preparing for a medical appointment.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Anna Bueno conducted a subsequent unannounced visit to the facility to continue the complaint investigation and deliver findings on the above allegations. LPA met with staff Liz Baclagan who was informed of the purpose of today’s visit. Licensee John Zhang and Administrator Satchel Lecita arrived during the visit. The investigation consisted of staff and resident interviews and review of relevant records. LPA was not able to interview Resident 1 (R1).

The allegations are that 1: Facility staff did not assist R1 with toileting needs; and 2: Facility staff did not assist R1 with preparing for a medical appointment. Records reviewed and staff interviews confirmed that this facility had an active Covid case on or around 07/23/2020 and contact with Covid-19 positive residents was limited to essential care as Covid-19 vaccines did not become available until December 2020. Records revealed that R1 was admitted to this facility on 06/28/2019. Review of physician's report and pre-admission appraisal state and staff interviews confirm that R1 does not have a cognitive impairment, was able to make their needs known, but required toileting and grooming assistance. Staff interviews revealed that they always assisted R1 with their

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 248-0339
LICENSING EVALUATOR NAME: Anna Bueno	TELEPHONE: 951-204-4307
LICENSING EVALUATOR SIGNATURE:	DATE: 04/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/09/2023

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-20200723084004

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: COOL MEADOW CARE	FACILITY NUMBER: 331880585
	VISIT DATE: 04/09/2023

NARRATIVE

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activities of daily living (ADLs) as R1 continued going to their weekly dialysis appointments. Staff interview further state that R1 and Administrator made arrangements for R1 to be transferred to a skilled nursing facility (SNF) to be adequately cared for on or around 07/23/2020 until R1 can safely return to this facility. Staff also confirmed that R1 moved to the SNF and did not come back to this facility. These allegations are therefore unsubstantiated.

A finding that the allegations are UNSUBSTANTIATED means that although the allegations may have happened or are 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 and provided to Licensee.

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 248-0339
LICENSING EVALUATOR NAME: Anna Bueno	TELEPHONE: 951-204-4307
LICENSING EVALUATOR SIGNATURE:	DATE: 04/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2023

LIC9099 (FAS) - (06/04)

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