331880616-7-29-2024-18-AS-JDHS-D7P9YJ-20240730234711

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 331880616
Report Date: 07/29/2024
Date Signed: 07/29/2024 01:59:18 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
01/22/2024 and conducted by Evaluator Kathleen Banrasavong

COMPLAINT CONTROL NUMBER: 18-AS-20240122145635

FACILITY NAME:	ANNA CARE LLC		FACILITY NUMBER:	331880616
ADMINISTRATOR:	BLANCAFLOR, ANNALISA		FACILITY TYPE:	740
ADDRESS:	26461 RIDGEMOOR RD		TELEPHONE:	(951) 309-1622
CITY:	SUN CITY	STATE: CA	ZIP CODE:	92586
CAPACITY:	6	CENSUS:	DATE:	07/29/2024
		UNANNOUNCED	TIME BEGAN:	01:20 PM
MET WITH:	Caregiver, April Ann Reyes		TIME COMPLETED:	02:10 PM

ALLEGATION(S):

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Staff interfered with resident's right to receive hospice care or other services

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Kathleen Banrasavong conducted an unannounced visit to deliver findings for a complaint investigation regarding the above allegation. LPA met with Caregiver, April Ann Reyes where LPA explained the purpose of the visit and the elements of the allegations. The investigation consisted of observation, interviews with staff members and residents, and records review.

On 01/22/2024, Community Care Licensing received a complaint alleging staff interfered with resident's right to receive hospice care or other services. It was reported that the facility staff interfered with the resident’s right to receive hospice care or other services. It was alleged that Administrator, Annalisa Blancaflor refused to let a staff member from the Hospice agency into the facility due to a precautionary rule to protect the residents and staff from Covid-19 exposure. Information obtained from interview with Administrator stated that she told Hospice Social Worker, volunteers, and aids that they could not come into the facility, but can meet with the Resident #1 (R1) out in the front porch.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Jazmond D Harris	TELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Kathleen Banrasavong	TELEPHONE: 951-622-3619
LICENSING EVALUATOR SIGNATURE:	DATE: 07/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2024

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-20240122145635

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: ANNA CARE LLC	FACILITY NUMBER: 331880616
	VISIT DATE: 07/29/2024

NARRATIVE

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It was advised that no residents or staff had Covid 19, but she wanted to implement this policy because the holidays were a time for Covid 19 cases. Blancaflor stated that she only allowed Registered nurse (RN) and the Licensed Vocational Nurse (LVN) to come into the facility. LPA interviewed staff members from the hospice company who stated that due to the condition of the R1, it was not in the best interest of R1 to meet with anyone outside of the facility. It was advised that the restriction started on November 30, 2023 and lasted until February 6, 2024. Documents were reviewed regarding hospice staff sign in dates to corroborate the visits attempted and successfully made. LPA was unable to interview R1 due to R1 passing away on March 20, 2024.

Based on LPA’s observations, interviews conducted, and record review(s), the allegation that staff interfered with resident’s rights to receive hospice care and other services, the preponderance of evidence standard has been met; therefore, the allegation is SUBSTANTIATED. This poses a health and safety and or personal rights risk to clients in care. The facility will be cited per Title 22 Regulations Division 6, 87468.1(a)(11), are being cited on the attached LIC 9099D.

An exit interview was conducted, and a copy of this report, the 9099-D, and appeal rights was discussed with and provided to the Caregiver, April Ann Reyes .

SUPERVISOR'S NAME: Jazmond D Harris	TELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Kathleen Banrasavong	TELEPHONE: 951-622-3619
LICENSING EVALUATOR SIGNATURE:	DATE: 07/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2024

LIC9099 (FAS) - (06/04)

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Control Number 18-AS-20240122145635

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: ANNA CARE LLC	FACILITY NUMBER: 331880616
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/29/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 08/09/2024 Section Cited HSC 87468.1(a)(11)	1 2 3 4 5 6 7	(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (11)To have their visitors...advocacy representatives, permitted to visit privately during reasonable hours and without prior notice,...This requirement was not being met as evidenced by:	1 2 3 4 5 6 7	Licensee shall read the regulation and provide a sign written affidavit of understanding the regulation section. Proof of correction is due to the Department 08/09/2024.
	8 9 10 11 12 13 14	The LPA conducted interviews with the Administrator and pertinent parties. It was confirmed that the Administrator restricted visitors for R1. This poses an immediate health and safety risk to residents in care.	8 9 10 11 12 13 14
	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: Jazmond D Harris	TELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Kathleen Banrasavong	TELEPHONE: 951-622-3619
LICENSING EVALUATOR SIGNATURE:	DATE: 07/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2024

LIC9099 (FAS) - (06/04)

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