331880655-4-13-2023-18-AS-JESL-CRBVL2-20230428163112

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 331880655
Report Date: 04/13/2023
Date Signed: 04/13/2023 02:31:10 PM

Substantiated

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
03/06/2023 and conducted by Evaluator Jesse Gardner

COMPLAINT CONTROL NUMBER: 18-AS-20230306131719

FACILITY NAME:	ASSURANCE HOME 2		FACILITY NUMBER:	331880655
ADMINISTRATOR:	FRANCESCA MORALES		FACILITY TYPE:	740
ADDRESS:	670 HIGHLAND DR		TELEPHONE:	(760) 507-8140
CITY:	PALM SPRINGS	STATE: CA	ZIP CODE:	92264
CAPACITY:	6	CENSUS: 7	DATE:	04/13/2023
		UNANNOUNCED	TIME BEGAN:	01:28 PM
MET WITH:	Segundina "Connie" Edwards, Caregiver		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Staff are not providing adequate supervision to prevent resident from wandering away from the facility

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Jesse Gardner arrived unannounced to conduct an investigation into the above allegation. LPA met with Caregiver Connie Edwards, and toured the facility. LPA conducted interviews with relevant outside sources, and reviewed documents in relation to Resident One (R1).

It was alleged that a lack of supervision resulted in a resident (R1; See LIC 811 Confidential Names List) leaving the facility and was found by Palm Springs Police Department.

Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: Deborah Mullen
LICENSING EVALUATOR NAME: Jesse Gardner
LICENSING EVALUATOR SIGNATURE:	DATE: 04/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/13/2023

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-20230306131719

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: ASSURANCE HOME 2	FACILITY NUMBER: 331880655
	VISIT DATE: 04/13/2023

NARRATIVE

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On the day of the incident, at around 10:00am, S1 was busy working in the kitchen, when R1 was not sitting in their normal place on the couch and went to look for R1. S1 notified R1’s family and told family R1 was missing.

Although record review indicated that R1 is able to leave the facility unassisted and does not have wandering behaviors, LPA learned that the Physician's Report that was reviewed, was written on limited information by the admitting hospice agency. Upon interview with hospice, hospice confirmed that R1 is not safe to be out on their own due to their confusion. R1 would not be capable of returning to the facility on their own. Based on interviews conducted and records reviewed, the preponderance of evidence standard has been met. Therefore, the above allegation is Substantiated, and the facility was cited per Title 22.

An exit interview was conducted where a copy of this amended report was provided along with copies of the LIC811, LIC9099D, and Appeal Rights.

SUPERVISORS NAME: Deborah Mullen
LICENSING EVALUATOR NAME: Jesse Gardner
LICENSING EVALUATOR SIGNATURE:	DATE: 04/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/13/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 3

Control Number 18-AS-20230306131719

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: ASSURANCE HOME 2	FACILITY NUMBER: 331880655
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/13/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 04/14/2023 Section Cited CCR 87705(k)(4)	1 2 3 4 5 6 7	87705 Care of Persons with Dementia(k) The following initial and continuing requirements must be met for the licensee to utilize delayed egres devices on exterior doors or perimeter fence gates:(4) Without violating Section 87468, Personal Rights, facility staff shall attempt to redirect a resident who attempts to leave the facility. The requirement was not being met as evidenced by:	1 2 3 4 5 6 7	Licensee agrees to conduct in-service training regarding the supervision of dementia residents and provide proof to LPA by POC date.
	8 9 10 11 12 13 14	Based on interviews with staff, and confidential witness, R1 was found outside of the facility and returned when staff were busy in the kitchen. This poses an immediate health and safety and/or personal rights 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.

SUPERVISORS NAME: Deborah Mullen
LICENSING EVALUATOR NAME: Jesse Gardner
LICENSING EVALUATOR SIGNATURE:	DATE: 04/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/13/2023

LIC9099 (FAS) - (06/04)

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