331880616-7-27-2021-18-AS-KCLS-C5TV2Z-20210812160357

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 331880616
Report Date: 07/27/2021
Date Signed: 07/27/2021 12:35:12 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
07/21/2021 and conducted by Evaluator Deborah Mullen

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20210721140831

FACILITY NAME:	ANNA CARE LLC		FACILITY NUMBER:	331880616
ADMINISTRATOR:	BLANCAFLOR, ANNALISA		FACILITY TYPE:	740
ADDRESS:	26461 RIDGEMOOR RD		TELEPHONE:	(909) 231-5700
CITY:	SUN CITY	STATE: CA	ZIP CODE:	92586
CAPACITY:	6	CENSUS: 6	DATE:	07/27/2021
		UNANNOUNCED	TIME BEGAN:	11:30 AM
MET WITH:	Annalisa Blancaflor, Licensee/Administrator		TIME COMPLETED:	12:45 PM

ALLEGATION(S):

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Staff hit resident
Staff restrained resident

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPAs) Deborah Mullen and Jesse Gardner conducted an unannounced visit to investigate the above allegations. LPAs met with Annalisa Blancaflor. LPAs interviewed resident 1 (R1) and staff.

Staff were interviewed and denied resident being hit or restrained. Staff stated R1 is delusional at times due to R1s diagnosis. R1 was interviewed and denied being hit. R1 stated he/she was being tied to the bed at night but that isn't happening anymore. R1 stated he/she would get up at night at staff didn't want him/her to fall. Additional witness interview were conducted. The witness denied observing any indication of R1 being hit or being tied up.

Based on the information obtained there is not enough evidence to state resident was hit or restrained by staff. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated at this time. An exit interview was conducted, and a copy of this report was reviewed with and provided to Ms. Blancaflor

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 836-2784
LICENSING EVALUATOR NAME: Deborah Mullen	TELEPHONE: (951) 212-0616
LICENSING EVALUATOR SIGNATURE:	DATE: 07/27/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2021

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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