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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331880689
Report Date: 01/12/2022
Date Signed: 01/12/2022 01:33:53 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
01/04/2022 and conducted by Evaluator Amy Goldenberg
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20220104122102
FACILITY NAME:SUNRISE AT EASTVALEFACILITY NUMBER:
331880689
ADMINISTRATOR:MANIQUIS, ROXANNEFACILITY TYPE:
735
ADDRESS:7323 PRAIRIE ISLAND CIRTELEPHONE:
(909) 730-1781
CITY:EASTVALESTATE: CAZIP CODE:
92880
CAPACITY:4CENSUS: 4DATE:
01/12/2022
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Rosario Maniquis TIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Facility provided an incomplete admission agreement.
INVESTIGATION FINDINGS:
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This unannounced visit conducted by Amy Goldenberg, Licensing Program Analyst (LPA), is being conducted to initiate the 10 day visit to investigate the above-mentioned complaint allegations.

During the course of the investigation, an interview with the facility administrator was conducted, a review of resident records was completed, and copies of the grievance policy, cash resource ledger for June 2021 and an admission agreement for R1 were obtained from the facility. LPA reviewed R1's P&I ledger.

In regard to facility provided an incomplete admission agreement, it is alleged that the licensee never disclosed in R1's admission agreement optional services for a monthly fee.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 248-0339
LICENSING EVALUATOR NAME: Amy GoldenbergTELEPHONE: (951) 248-0351
LICENSING EVALUATOR SIGNATURE:

DATE: 01/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2022
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 5
Control Number 18-AS-20220104122102
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: SUNRISE AT EASTVALE
FACILITY NUMBER: 331880689
VISIT DATE: 01/12/2022
NARRATIVE
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R1's conservator was never notified that R1 was being charged for WIFI and cable TV. It is not disclosed as part of the admission agreement, however, the administrator reports that this was discussed verbally at the time of admission. Review of R1's admission agreement confirmed that the optional charges for internet and WIFI are not specified. Interview with facility administrator Rosario Maniquis revealed that there was already discussion surrounding the issue of the charges during a phone call with R1's Regional Center Representatives on 01/05/2022 for review of the cable charge and on 01/11/2022 to further discuss internet charges. It was agreed that the monies for these items would be refunded to R1's P&I account. Review of the P&I ledger revealed deductions for internet. Review R1's P&I ledger for January 2022 revealed entries on 01/05/2022 and 01/12/2022 for reimbursements for all of the deductions for WIFI and internet. LPA review of R1's P&I fund revealed that the ledger and available monies in the fund are matching signifying the refund has been made further confirming that R1 was eroniously charged for these items without disclosure.

Based on the available information obtained during this complaint investigation, we have substantiated the complaint allegation as valid. We have therefore found that a violation has occurred based on the preponderance of available evidence. A copy of this report along with appeal rights are being reviewed with, and furnished to the facility representative. Please see LIC 9099D.
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 248-0339
LICENSING EVALUATOR NAME: Amy GoldenbergTELEPHONE: (951) 248-0351
LICENSING EVALUATOR SIGNATURE:

DATE: 01/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 5
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
01/04/2022 and conducted by Evaluator Amy Goldenberg
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20220104122102

FACILITY NAME:SUNRISE AT EASTVALEFACILITY NUMBER:
331880689
ADMINISTRATOR:MANIQUIS, ROXANNEFACILITY TYPE:
735
ADDRESS:7323 PRAIRIE ISLAND CIRTELEPHONE:
(909) 730-1781
CITY:EASTVALESTATE: CAZIP CODE:
92880
CAPACITY:4CENSUS: 4DATE:
01/12/2022
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Rosario Maniquis TIME COMPLETED:
02:00 PM
ALLEGATION(S):
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The facility is not following their grievance policy program plan.
INVESTIGATION FINDINGS:
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This unannounced visit conducted by Amy Goldenberg, Licensing Program Analyst (LPA), is being conducted to initiate the 10 day visit to investigate the above-mentioned complaint allegations.

During the course of the investigation, an interview with the facility administrator was conducted with staff, a review of resident records was completed, and copies of the grievance policy, cash resource ledger for June 2021 and an admission agreement for R1 were obtained from the facility.

Review of the greivance policy on page 14 of the admission agreement states the following:
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 248-0339
LICENSING EVALUATOR NAME: Amy GoldenbergTELEPHONE: (951) 248-0351
LICENSING EVALUATOR SIGNATURE:

DATE: 01/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 18-AS-20220104122102
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: SUNRISE AT EASTVALE
FACILITY NUMBER: 331880689
VISIT DATE: 01/12/2022
NARRATIVE
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 "The administrator will review the Consumer Grievance Policy with the consumer and conservator/family at the time of admission and then one time per year thereafter. The administrator, consumer and conservator/family will sign a form acknowledging the review of the procedure. All staff will be trained to provide assistance to the consumers on filling out the consumer grievance form. The form is created for the consumer to fill out. on their own if they wish. A response to the consumer grievance request will occur within 24 hours upon receiving the notification via phone call, meeting or writing. If the greivance is not resolved, contact Regional Center Services Coordinator, Community Care Licensing, or Clients Rights Advocates. The consumer will be counseled that they have a right to contact their Regional Center Service Coordinator (909) 890-3000 or the community Care Licensing (951) 782-4207".

It is alleged that R1 and their conservator did not receive a copy of the grievance policy. Review of the policy cited above does not indicate that a copy of the grievance form would be provided at the time of admission. Interview of the facility Administrator revealed that a copy of the grievance form would be provided at request by the client/conservator and instruction would be provided. The administrator further indicated that to their knowledge, although areas of concern were discussed with R1's conservator, a request for the form was never made. The administrator revealed that the grievance policy was reviewed and the procedure was discussed at the time of admission. A copy of the form signed on 04/16/2021 by R1's conservator confirms review of Consumers Rights, House Rules, and Grievance Procedures.

Information obtained is inconclusive as to what information was disclosed between the parties at the time of admission on 04/16/2021. Based on the aforementioned, there is not a clear indication that a violation has occurred. We have found the complaint allegation is unsubstantiated, although the allegation may have happened or is valid: there is not a preponderance of the evidence to prove that the alleged violation occurred. A copy of this report is being reviewed with and furnished to the facility representative.
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 248-0339
LICENSING EVALUATOR NAME: Amy GoldenbergTELEPHONE: (951) 248-0351
LICENSING EVALUATOR SIGNATURE:

DATE: 01/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 18-AS-20220104122102
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: SUNRISE AT EASTVALE
FACILITY NUMBER: 331880689
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/12/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/19/2022
Section Cited
CCR
80068(c)(3)(B)
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Admission Agreement-(c) Admission agreements must specify the following: (3) Payment provisions, including the following:
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Licensee to submit to Community Care Licensing an ammended Admission Agreement for review which includes the optional services and their rates by POC due date.
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 (B) Optional services rates. The facility failed to meet this requirement as evidenced by the admission agreement not including optional service rates.
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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: Nedra BrownTELEPHONE: (951) 248-0339
LICENSING EVALUATOR NAME: Amy GoldenbergTELEPHONE: (951) 248-0351
LICENSING EVALUATOR SIGNATURE:

DATE: 01/12/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 5