331880722-1-3-2024-18-AS-RSTS-CZE2E7-20240111161929

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 331880722
Report Date: 01/03/2024
Date Signed: 01/03/2024 01:30:48 PM

Unsubstantiated

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
12/13/2021 and conducted by Evaluator Jesse Gardner

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20211213172614

FACILITY NAME:	DESERT HILLS MEMORY CARE CENTER		FACILITY NUMBER:	331880722
ADMINISTRATOR:	HUDSON, CHANTELLE		FACILITY TYPE:	740
ADDRESS:	25818 COLUMBIA ST		TELEPHONE:	(951) 652-1837
CITY:	HEMET	STATE: CA	ZIP CODE:	92544
CAPACITY:	58	CENSUS: 35	DATE:	01/03/2024
		UNANNOUNCED	TIME BEGAN:	12:40 PM
MET WITH:	Shannon Moore, Administrator		TIME COMPLETED:	01:45 PM

ALLEGATION(S):

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Inappropriate interactions between resident's in care.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Jesse Gardner conducted an unannounced subsequent complaint visit to the facility. LPA met with Administrator Shannon Moore informed them of the purpose of this visit. During this investigation LPA conducted interviews with staff and residents; obtained supportive documentation for review to assist with determining the findings for the above noted allegation. The following was determined.

Allegation #1 – Inappropriate actions between residents in care. The allegation stated that Resident One (#R1) was involved in a physical altercation with Resident Two (#R2). Allegedly, R1 threw a punch, and struck R2. When R1 punched R2, R2 bit R1 on the hand, causing a minor breakage of the skin. Staff interview revealed that both

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Rikesha Stamps	TELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Jesse Gardner	TELEPHONE: (951) 205-2683
LICENSING EVALUATOR SIGNATURE:	DATE: 01/03/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/03/2024

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-20211213172614

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: DESERT HILLS MEMORY CARE CENTER	FACILITY NUMBER: 331880722
	VISIT DATE: 01/03/2024

NARRATIVE

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R1, and R2 were transported to the hospital for evaluation for minor medical care, and both residents returned to the facility without further incident.

Through record review, LPA discovered that R1 has aggressive behaviors documented in their Physician’s Report, and R1’s care plan noted that R1 needs supervision for a multitude of reasons, including aggression. Staff schedule revealed that staff were present in the facility providing supervision to residents. Interviews with staff confirmed that staff were in the area, and further revealed that they responded quickly to the outburst of behaviors between the residents; thus, this allegation was Unsubstantiated.

A finding of UNSUBSTANTIATED means that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur.

An exit interview was conducted, and a copy of this report was reviewed with and provided to Administrator Shannon Moore.

SUPERVISOR'S NAME: Rikesha Stamps	TELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Jesse Gardner	TELEPHONE: (951) 205-2683
LICENSING EVALUATOR SIGNATURE:	DATE: 01/03/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/03/2024

LIC9099 (FAS) - (06/04)

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