331880722-7-22-2021-18-AS-EMAN-C5QQE8-20210809120555

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 331880722
Report Date: 07/22/2021
Date Signed: 07/22/2021 02:17:18 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
08/31/2020 and conducted by Evaluator Natalie Gayoso

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20200831123512

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: 38	DATE:	07/22/2021
		UNANNOUNCED	TIME BEGAN:	11:14 AM
MET WITH:	Chantelle Hudson		TIME COMPLETED:	02:25 PM

ALLEGATION(S):

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Resident sustained an injury while in care.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Natalie Gayoso conducted an unannounced visit for the purpose of following up on a complaint investigation and deliver findings. LPA met with Administrator Chantelle Hudson and explain the purpose of today's visit. The investigation consisted of interviews with pertinent parties and file review.
The allegation indicates resident sustained an injury while in care. Interviews with staff revealed Resident #1 (R1) tries to stand and/or transfer on their own and is at risk for falls. On the day of the incident R1 was found in bed with an unexplained laceration above left eye. Staff believe R1 must have hit their head against their night stand when rolling over. Interview with Staff #2 (S2) stated they conducted a routine check on R1 at 7AM and did not see any blood or lacerations at that time on R1's face. The AM caregiver, Staff #3 (S3) checked on R1 at 6AM and 8AM and no injuries were reported. It wasn't until the 9AM routine check did S3 report to S2 that R1 had a laceration above the left eyebrow. R1 was assessed, first aid applied, and was sent out to the hospital. S2 stated that R1 has dementia and was unable to explain how they obtained the laceration when questioned

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Natalie Gayoso	TELEPHONE: (951) 290-1102
LICENSING EVALUATOR SIGNATURE:	DATE: 07/22/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2021

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-20200831123512

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: DESERT HILLS MEMORY CARE CENTER	FACILITY NUMBER: 331880722
	VISIT DATE: 07/22/2021

NARRATIVE

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LPA reviewed R1's service plan and verified R1 was at fall risk. R1's physician report states R1 has dementia and is non-ambulatory and bed bound. Per doctor's orders, R1 is to have mattress on floor during sleep hours for safety due to falls.

Based on interviews, which were conducted, and records review, the allegations are UNSUBSTANTIATED. A finding of UNSUBSTANTIATED means that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur.

No deficiencies were cited during this visit.
An exit interview was conducted, and a copy of this report was provided to the Administrator..

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Natalie Gayoso	TELEPHONE: (951) 290-1102
LICENSING EVALUATOR SIGNATURE:	DATE: 07/22/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2021

LIC9099 (FAS) - (06/04)

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