331880585-5-22-2024-18-AS-TDAN-D5ST8K-20240531143030

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 331880585
Report Date: 05/22/2024
Date Signed: 05/22/2024 01:02:14 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 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
05/16/2024 and conducted by Evaluator Janira Arreola

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20240516110321

FACILITY NAME:	COOL MEADOW CARE		FACILITY NUMBER:	331880585
ADMINISTRATOR:	PENDING		FACILITY TYPE:	740
ADDRESS:	29787 COOL MEADOW DR		TELEPHONE:	(951) 246-0214
CITY:	MENIFEE	STATE: CA	ZIP CODE:	92587
CAPACITY:	6	CENSUS: 4	DATE:	05/22/2024
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Licensee, Long Zhang		TIME COMPLETED:	01:15 PM

ALLEGATION(S):

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Staff refused to accept resident back to the facility

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Janira Arreola, conducted an unannounced visit to the facility in order to investigate the above allegations. LPA met with Licensee, Long Zhang, who was informed of the purpose of the visit. During the visit, LPA conducted interviews and conducted records reviews.

It was alleged that “Staff refused to accept resident back to the facility”. It was alleged that Resident #1 (R1) was not accepted back to the facility due to Staff #1 (S1) citing nonpayment and inability to care for R1’s condition. LPA reviewed the regional office accountability log for received eviction notices. None were found for R1.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Tricia Danielson	TELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Janira Arreola	TELEPHONE: 951-233-6759
LICENSING EVALUATOR SIGNATURE:	DATE: 05/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2024

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 3

Control Number 18-AS-20240516110321

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: COOL MEADOW CARE	FACILITY NUMBER: 331880585
	VISIT DATE: 05/22/2024

NARRATIVE

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Staff interviews revealed that R1 was placed by a hospital which transported R1 to the facility (2) hours after S1 verbally accepted R1. The resident was placed on 5/7/2024. No medical records or rental agreements were signed as evidenced by staff interview and records review.

Staff interviews revealed that R1 had behaviors such as becoming physical with staff, destruction of property, and wandering. Staff interviews revealed that R1 required 1:1 supervision to ensure safety and could not be cared for at the facility. Within (5) days, on 5/12/2024 Staff revealed R1 was transported to the hospital due to an unwitnessed fall and was not accepted back to the facility by S1.

Therefore, based on the records review and interviews conducted, it is found that the allegation is substantiated.

Findings that are substantiated mean that the preponderance of the evidence standard has been met. Deficiencies were cited under California Code of Regulations Title 22.

An exit interview was conducted with Licensee, John Zhang where this report, deficiency page and appeal rights were reviewed and provided to them.

SUPERVISOR'S NAME: Tricia Danielson	TELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Janira Arreola	TELEPHONE: 951-233-6759
LICENSING EVALUATOR SIGNATURE:	DATE: 05/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 18-AS-20240516110321

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: COOL MEADOW CARE	FACILITY NUMBER: 331880585
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/22/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 05/23/2024 Section Cited CCR 87468.2(a)(20)	1 2 3 4 5 6 7	Additional Personal Rights of Residents…(a) In addition to the rights listed ... residents...shall have all of the following personal rights: (20) To be protected from involuntary transfers, discharges, and evictions....	1 2 3 4 5 6 7	The licensee agreed to send the LPA a written step by step plan on how they will screen resident before admission to evaluate compatibility and avoid unecessary transfers.
	8 9 10 11 12 13 14	This requirement was not met as evidenced by: Based on interviews and records review it was found that the facility did not accept R1 back from the hospital. This poses an immediate health safety or personal rights risk to residents in care.	8 9 10 11 12 13 14	This is due by the POC due date to the LPA.
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Tricia Danielson	TELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Janira Arreola	TELEPHONE: 951-233-6759
LICENSING EVALUATOR SIGNATURE:	DATE: 05/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2024

LIC9099 (FAS) - (06/04)

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