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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331880782
Report Date: 05/17/2023
Date Signed: 05/17/2023 11:29:43 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 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
10/04/2022 and conducted by Evaluator Ryan Gardner
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20221004180307
FACILITY NAME:MIMOSA HIGHPOINTEFACILITY NUMBER:
331880782
ADMINISTRATOR:STEWART, LEONAFACILITY TYPE:
735
ADDRESS:15160 MIMOSA DRTELEPHONE:
(562) 682-0946
CITY:LAKE ELSINORESTATE: CAZIP CODE:
92530
CAPACITY:4CENSUS: 4DATE:
05/17/2023
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Maureen Sevilla - House ManagerTIME COMPLETED:
11:40 AM
ALLEGATION(S):
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9
Staff hit resident.
Staff did not treat resident with dignity or respect.
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Ryan Gardner and Mary Rico conducted an unannounced visit to deliver findings for the above complaint allegations that were initiated on 10/7/2022. LPAs met with House Manager Maureen Sevilla and explained the reason for the visit.

For allegation, Staff hit resident: It was alleged that Staff S5 hit Client C1 on their butt and their head during a diaper change.

During interviews with clients, LPA attempted to interview C1, C1 did not respond to questioning verbally. C3 and C4 were present in the living room when the diaper change and altercation happened between C1 and S5. C3 and C4 saw S5 hit C1 on their butt and their head. C3 and C4 stated that C1 was physically and emotionally upset after they were hit. C2 was not present during the altercation but was informed later by C3 and C4 about what they saw happen between C1 and S5.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Ryan Gardner
LICENSING EVALUATOR SIGNATURE:

DATE: 05/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2023
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 56-AS-20221004180307
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: MIMOSA HIGHPOINTE
FACILITY NUMBER: 331880782
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/17/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/18/2023
Section Cited
CCR
80072(a)(3)
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80072(a)(3). Personal Rights. (a)Except for children’s residential facilities, each client shall have personal rights which include, but are not limited to, the following:
(3) To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse, or other actions of a punitive nature, including but not limited to: interference with the daily living functions, including eating, sleeping, or toileting; or withholding of shelter, clothing, medication or aids to physical functioning.
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The licensee has agreed to read regulation 80072 entirely and send LPA a self-certified letter that the regulation was read and understood. The licensee retrained staff on personal rights on 9/30/22 and provided documents to LPA. The POC is due by 5/18/2023.
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Based on interview, the licensee did not comply with the section cited above evidenced by S5 hitting C1 on their butt and head which poses an immediate health, safety, or personal rights risk to persons in care.
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Type B
05/19/2023
Section Cited
CCR
80072(a)(1)
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80072(a)(1). Personal Rights.
(a) Except for children’s residential facilities, each client shall have personal rights which include, but are not limited to, the following:(1) To be accorded dignity in his/her personal relationships with staff and other persons.
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The licensee has agreed to read regulation 80072 entirely and send LPA a self-certified letter that the regulation was read and understood. The licensee retrained staff on personal rights on 9/30/22 and provided documents to LPA. The POC is due by 5/19/2023.
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Based on interview, the licensee did not comply with the section cited above evidenced by S5 yelling, intimidating, and treating the clients unfairly which poses a potential health, safety, or personal rights risk to persons 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.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Ryan Gardner
LICENSING EVALUATOR SIGNATURE:

DATE: 05/17/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 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
10/04/2022 and conducted by Evaluator Ryan Gardner
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20221004180307

FACILITY NAME:MIMOSA HIGHPOINTEFACILITY NUMBER:
331880782
ADMINISTRATOR:STEWART, LEONAFACILITY TYPE:
735
ADDRESS:15160 MIMOSA DRTELEPHONE:
(562) 682-0946
CITY:LAKE ELSINORESTATE: CAZIP CODE:
92530
CAPACITY:4CENSUS: 4DATE:
05/17/2023
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Maureen Sevilla - House ManagerTIME COMPLETED:
11:40 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not dispense medication according to the physician directions.
Staff did not change residents diaper in a timely manner.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analysts (LPAs) Ryan Gardner and Mary Rico conducted an unannounced visit to deliver findings for the above complaint allegations were initiated on 10/7/2022. LPAs met with House Manager Maureen Sevilla and explained the reason for the visit.

For allegation, Staff did not dispense medication according to the physician directions. It was alleged that the client’s medication was dispensed late and not given at the correct time.

During interviews with clients, the clients stated that their medication was given to them at the correct time and they did not have any issues with their medication being dispensed late by staff.

During interviews with staff, the staff denied giving medications to the clients late. The staff indicated that each client has a MAR (medication record) that is initialed by the staff when dispensing the medication.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Ryan Gardner
LICENSING EVALUATOR SIGNATURE:

DATE: 05/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 56-AS-20221004180307
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: MIMOSA HIGHPOINTE
FACILITY NUMBER: 331880782
VISIT DATE: 05/17/2023
NARRATIVE
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The clients MAR includes a time for each medication and staff will dispense the medication based on the time noted in the clients MAR.

During document review, LPA reviewed the client’s MARs for September 2022 and October 2022. LPA discovered that the staff is initialing next to each medication when it is dispensed. The clients MARs include a dispense time for each medication and/or an as needed note for PRN (pro re nata) medications.

For allegation, Staff did not change residents diaper in a timely manner:

During interviews with clients, three (3) clients stated that they do not wear diapers. One (1) client did not verbally respond to the question.

During interviews with staff, staff denied that the client’s diapers were not changed in a timely manner. The staff stated that there is only one (1) client that wears diapers in the home. The client is changed every thirty (30) minutes to two (2) hours depending on when the diaper is soiled.

Based on the evidence found during the investigation, the two (2) allegations listed above are deemed UNSUBSTANTIATED. A finding that the complaints are UNSUBSTANTIATED means although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur.

During today’s visit, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations.

An exit interview was conducted, and this report was discussed and provided to House Manager Maureen Sevilla, along with a copy of the appeal rights.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Ryan Gardner
LICENSING EVALUATOR SIGNATURE:

DATE: 05/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 56-AS-20221004180307
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: MIMOSA HIGHPOINTE
FACILITY NUMBER: 331880782
VISIT DATE: 05/17/2023
NARRATIVE
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During interviews with staff, LPA was informed that on September 29, 2022, S7 was in the kitchen while S5 was in the living room with C1, C3, C4. From the kitchen, S7 heard a loud hit. S7 walked into the living room and saw S5 hit C1 on their butt. S7 stated that C1 was visibly shaken and emotionally upset. After the altercation, C1 was flinching at the sight of S5. The other staff stated that they were not working the day of the altercation but believed that S5 was capable of hitting C1 based on prior behaviors of being intimating, yelling, and being aggressive towards the clients. The staff that were not present were informed by C3 and C4 that they saw S5 hit C1. The staff stated that the clients are afraid of S5. Staff states that soon as S5 walks into a room, the demeanor of the clients changes and its visible that the clients are uncomfortable. S5 denied there was an alternation with hitting C1 during a diaper change. S5 stated there was a diaper change in the living room and only C5 and C1 were present.

For allegation, Staff did not treat resident with dignity or respect: It was alleged that the clients are yelled at by S5, scared of S5, and treated unfairly by S5.

During interviews with clients, C3 and C4 saw S5 hit C1 and yell at C1 during a diaper change. The clients stated they have had experiences where S5 yelled at them, treated them unfairly, and has seen S5 treat the other clients unfairly.

During interviews with staff, the staff stated that the clients are intimated by S5 and their whole demeanor changes when S5 is present. Staff stated that S5 yells and intimates the clients. The staff stated that the clients are afraid of S5. Interview with S5 revealed that S5 denied treating the clients unfairly, yelling at the clients, or intimating the clients.

Based on the evidence gathered during the investigation, the two (2) allegations listed above are deemed SUBSTANTIATED. A finding that the complaints are SUBSTANTIATED means that the allegations are valid because the preponderance of evidence the standard has been met.

During today’s visit, two (2) deficiencies were cited per Title 22, Division 6, of the California Code of Regulations.

An exit interview was conducted, and this report (LIC9099) and LIC9099D was discussed and provided to House Manager Maureen Sevilla, along with a copy of the appeal rights.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Ryan Gardner
LICENSING EVALUATOR SIGNATURE:

DATE: 05/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 5