331880782-10-24-2023-56-AS-EMAN-CX4SJW-20231030135549

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 331880782
Report Date: 10/24/2023
Date Signed: 10/24/2023 09:31:19 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
10/17/2023 and conducted by Evaluator Ryan Gardner

PUBLIC

COMPLAINT CONTROL NUMBER: 56-AS-20231017083828

FACILITY NAME:	MIMOSA HIGHPOINTE		FACILITY NUMBER:	331880782
ADMINISTRATOR:	STEWART, LEONA		FACILITY TYPE:	735
ADDRESS:	15160 MIMOSA DR		TELEPHONE:	(562) 682-0946
CITY:	LAKE ELSINORE	STATE: CA	ZIP CODE:	92530
CAPACITY:	4	CENSUS: 3	DATE:	10/24/2023
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Maureen Sevilla - House Manager		TIME COMPLETED:	09:40 AM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff hit resident resulting in injuries.
Staff engaged in a verbal altercation with resident.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Ryan Gardner made an unannounced visit to deliver findings for the allegations listed above. LPA stated the purpose of the visit and was granted entry and met with Facility Manager Maureen Sevilla. The investigation consisted of client interviews, staff interviews, and document review.

For allegation, Staff hit resident resulting in injuries:

Interviews with clients and the staff revealed that on 10/13/2023 Staff S1 accused Client C1 of stealing a pair of S1’s headphones. During the incident, S1 hit C1 on the left side of C1’s face. S1 scratched C1 on the left side of C1’s face. C1 had scratches, red inflamed marks, and minor bleeding from the incident. Document review of a picture of C1’s face revealed that C1 had scratches, red inflamed marks, and minor bleeding from the incident. The incident was witnessed by Staff S2 and Client C2. S2 and C2 both witnessed S1 hit C1’s face and scratch C1’s face.

Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Ryan Gardner
LICENSING EVALUATOR SIGNATURE:	DATE: 10/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2023

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 3

Control Number 56-AS-20231017083828

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: 10/24/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 10/25/2023 Section Cited CCR 80072(a)(3)	1 2 3 4 5 6 7	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.	1 2 3 4 5 6 7	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 has agreed to retrain all staff on personal rights and provide documented proof of the training to LPA by the POC due date.
	8 9 10 11 12 13 14	Based on interview and document review, the licensee did not comply with the section cited above evidenced by S1 hitting C1 on the face and S1 scratching C1 on the face which poses an immediate health, safety, or personal rights risk to persons in care.	8 9 10 11 12 13 14	The POC is due by 10/25/2023.
Type B 10/25/2023 Section Cited CCR 80072(a)(1)	1 2 3 4 5 6 7	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.	1 2 3 4 5 6 7	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 has agreed to retrain all staff on personal rights and provide documented proof of the training to LPA by the POC due date.
	8 9 10 11 12 13 14	Based on interview, the licensee did not comply with the section cited above evidenced by S1 yelling at C1 which poses a potential health, safety, or personal rights risk to persons in care.	8 9 10 11 12 13 14	The POC is due by 10/25/2023.

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: 10/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 56-AS-20231017083828

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: 10/24/2023

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

S1 admitted that they scratched C1’s face leaving injuries on C1’s face. S1 admitted that they were unprofessional and apologized for their behavior.

For allegation, Staff engaged in a verbal altercation with resident:

Interviews with clients and the staff revealed that on 10/13/2023 Staff S1 accused Client C1 of stealing a pair of S1’s headphones. During this incident, S1 yelled at C1. Staff S2 and Client C2 witnessed S1 yell at C1. S1 admitted that they yelled at C1 when they accused C1 of stealing their headphones. S1 admitted that they were unprofessional and apologized for their behavior.

Based on evidence obtained 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 of 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. The facility will also be issued two (2) civil penalties totaling an amount of $500 dollars for repeating the same violations within a twelve (12) month period.

An exit interview was conducted, and this report (LIC9099), LIC9099D, and two (2) LIC421FC forms were discussed and provided to Facility Manager Maureen Sevilla, along with a copy of the appeal rights.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Ryan Gardner
LICENSING EVALUATOR SIGNATURE:	DATE: 10/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 3