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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331880689
Report Date: 02/03/2022
Date Signed: 02/03/2022 02:00:17 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
01/28/2022 and conducted by Evaluator Amy Goldenberg
COMPLAINT CONTROL NUMBER: 18-AS-20220128141943
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:
02/03/2022
UNANNOUNCEDTIME BEGAN:
12:35 PM
MET WITH:Roxanne ManiquisTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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-Licensee failed to complete an Appraisal Needs and Services upon client's admission to the facility.
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 allegation.

During the course of this investigation visit LPA reviewed California Code of Regulations Title 22 Division 6, section 80068.2, Needs and Services Plan. LPA additionally reviewed the resident records (R1); Admission Agreement, Individual Program Plan (IPP).

Investigation revealed the following: 80068.2 (b)(1) states the following,"If the client has an existing needs appraisal or Individual Program Plan (IPP) completed by a placement agency, or a consultant for the placement agency, the Department may consider the plan to meet the requirements of this section provided that:
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amy Goldenberg
LICENSING EVALUATOR SIGNATURE:

DATE: 02/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2022
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 4
Control Number 18-AS-20220128141943
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: 02/03/2022
NARRATIVE
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The needs appraisal or IPP is not more than one year old."

LPA learned that R1 moved into the facility 04/16/2021 according to information obtained through review of their record. Facility Needs and Service Plan was accepted at the time of admission was prepared as an Individual Program Plan (IPP) prepared by Inland Regional Center and was dated 12/10/2018. This plan is more than one year old and does not meet the requirement of the regulation in question.

We have substantiated the complaint allegation as valid and 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.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amy Goldenberg
LICENSING EVALUATOR SIGNATURE:

DATE: 02/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 18-AS-20220128141943
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: 02/03/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type B
02/09/2022
Section Cited
CCR
80068.2(b)(1)
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If the client has an existing needs appraisal or individual program plan (IPP) completed by a placement agency, or a consultant for the placement agency,
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Licensee to review regulation section cited and provided a statement of understanding regarding the regulatory requirement regarding Needs and Service Plans by POC due date.
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the Department may consider the plan to meet the requirements of this section provided that: The needs appraisal or IPP is not more than one year old. This requirement has not been met as evidenced by IPP on file is dated 12/10/2018. and is more than one year from the date of admission, 4/16/2021.
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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.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amy Goldenberg
LICENSING EVALUATOR SIGNATURE:

DATE: 02/03/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 4