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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880774
Report Date: 03/22/2022
Date Signed: 03/22/2022 01:57:26 PM

Document Has Been Signed on 03/22/2022 01:57 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:RAINCROSS AT RIVERSIDEFACILITY NUMBER:
331880774
ADMINISTRATOR:JUDITH PIERFAXFACILITY TYPE:
740
ADDRESS:5232 CENTRAL AVENUETELEPHONE:
(951) 785-1200
CITY:RIVERSIDESTATE: CAZIP CODE:
92504
CAPACITY: 120CENSUS: 62DATE:
03/22/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:William Lewallen - Resident Care DirectorTIME COMPLETED:
02:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Crystal Colvin arrived at the facility unannounced for the purpose of investigating a complaint (#18-AS-20220317170451). During LPA Colvin's inspection, the following observations were made:
  • Unavailable Records for Inspection - In relation to the aforementioned complaint investigation, LPA Colvin requested to see an updated Admissions Agreement and fee schedule breakdown for a resident (R1), as only the original Admissions Agreement from 2017 was present in the file. After an extended period of time, Business Manager Joselynn Munoz informed LPA Colvin that she was unable to obtain a copy of the Agreement from her contact at the company's regional office, and could not confirm how the document is stored. Business Manager Joselynn additionally examined the file for R1 which had been provided to LPA Colvin, and could not locate any updated information for R1's new charges for care at the facility. Deficiency cited.

  • Lack of Required Approval/Signatures - After Business Manager Joselynn had contacted the company's regional office to inquire about the new Admissions Agreement and proof that it was provided to R1's Power of Attorney (POA), Joselynn informed LPA Colvin that she was advised that the Licensee did not require for the new Admissions Agreement to be signed, therefore, the facility (and regional office) does not have a signature on file for the new Admissions Agreement and charges for R1. Deficiency cited.

  • Changes in Plan of Operation - Prior to arriving at the facility, LPA Colvin reviewed Community Care Licensing's (CCL) file for the facility, including the Admissions Agreement which was approved with the facility's license in 2020. LPA Colvin observed that the Admissions Agreement on file with CCL does not follow the same fee structure (points versus levels) that is reflected in R1's billing history.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Crystal Colvin
LICENSING EVALUATOR SIGNATURE: DATE: 03/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/22/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: RAINCROSS AT RIVERSIDE
FACILITY NUMBER: 331880774
VISIT DATE: 03/22/2022
NARRATIVE
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  • Additionally, consultation with the LPA that oversees this facility (LPA Stephanie Torres), confirms that CCL has not received anything from the Licensee in regards to major changes in the facility's operation, such as changes in the Admissions Agreement and how residents are charged for care provided. Deficiency cited.
  • Past Due Licensing Fees - Prior to LPA Colvin's arrival at the facility, LPA Colvin reviewed the facility's standing with CCL, which includes the timely payment of annual licensing fees. LPA Colvin observed that the licensee is currently behind in payment with the facility's annual fees, and has accrued a late fee as a result. Current outstanding balance owned to CCL is $2,973.00. Deficiency cited.



LPA Colvin conducted an exit interview with Resident Care Director William Lewallen, where a copy of this report, LIC809D, and appeal rights was provided.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Crystal Colvin
LICENSING EVALUATOR SIGNATURE:

DATE: 03/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2022
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 03/22/2022 01:57 PM - It Cannot Be Edited


Created By: Crystal Colvin On 03/22/2022 at 01:09 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: RAINCROSS AT RIVERSIDE
FACILITY NUMBER: 331880774

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/22/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/28/2022
Section Cited
CCR
87208(a)(2)

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Plan of Operation: (a) Each facility shall have and maintain a current, written definitive plan of operation...Any significant changes...shall be submitted to the licensing agency for approval. The plan...shall contain the following: (2) A copy of the Admission Agreement... This requirement was not met by:
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Licensee agrees to provide CCL with an updated copy of their Admissions Agreement for review/approval. Licensee to submit the new Admissions Agreement, as well as any other changes since their initial application, to CCL by Plan of Correction date of 3/28/22.
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Based on record review, the Licensee did not comply with at least one aspect of the facility's Plan of Operation. LPA Colvin observed that CCL did not have a current copy of the revised Admissions Agreement (which has a substantially different fee structure) on file. This is a potential personal rights violation.
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Type B
03/28/2022
Section Cited
CCR87156(a)

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Licensing Fees: (a) An applicant or licensee shall be charged fees as specified in Health and Safety Code section 1569.185. This requirement was not met as evidenced by:
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Licensee agrees to pay all outstanding fees due to CCL. Licensee may self-certify to LPA Colvin once all fees have been paid. Licensee to pay fees and submit self-certification to LPA Colvin by the Plan of Correction date of 3/28/22.
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Based on record review, the Licensee has not complied with the above regulation with annual fees assessed 12/1/21 and late fee assessed 3/3/22. LPA Colvin observed that the Licensee has not paid the most recent annual fees and has accured a late charge. This is a potential personal rights violation to residents in care.
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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:Joel Esquivel
LICENSING EVALUATOR NAME:Crystal Colvin
LICENSING EVALUATOR SIGNATURE:
DATE: 03/22/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/22/2022


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/22/2022 01:57 PM - It Cannot Be Edited


Created By: Crystal Colvin On 03/22/2022 at 01:21 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: RAINCROSS AT RIVERSIDE
FACILITY NUMBER: 331880774

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/22/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/23/2022
Section Cited
CCR
87506(a)

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Resident Records: (a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff. This requirement was not met as evidenced by:
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Licensee agrees to provide LPA Colvin with a complete copy of R1's new Admissions Agreement and rate changes/break down of charges by the Plan of Correction date of 3/23/22. LPA Colvin additionally reccomends for the facility to keep digital or printed copies for all residents' files on hand at the facility.
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Based on record review, the Licensee did not comply with the above regulation with at least one resident (R1). LPA Colvin observed that the facility did not have a copy of R1's new Admissions Agreement or rate change on file. This is an immediate personal rights violation, as it violates CCL's inspection authority.
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Type A
03/31/2022
Section Cited
CCR87507(c)

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Admissions Agreeement: (c) Admission agreements shall be signed and dated, acknowledging the contents of the document, by the resident or the resident’s representative... Attachments to the agreement may be utilized as long as they are also signed and dated as prescribed above.
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Licensee agrees to obtain a signed copy of the new Admissions Agreement for R1, or obtain proof of refusal of signature (such as email communication or signed statement) from R1's POA. Licensee to provide either requested document to LPA Colvin by Plan of Correction date of 3/31/22.
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This requirement was not met by: Based on interview with Business Manager, the Licensee did not require the new Admissions Agreement (2021/2022) to be signed by R1's POA. This is an immedaite personal rights violation, as R1's POA was not provided an opportunity to review or reject charges.
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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:Joel Esquivel
LICENSING EVALUATOR NAME:Crystal Colvin
LICENSING EVALUATOR SIGNATURE:
DATE: 03/22/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/22/2022


LIC809 (FAS) - (06/04)
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