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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331880802
Report Date: 06/15/2023
Date Signed: 06/21/2023 09:07:24 AM

Substantiated


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
09/28/2021 and conducted by Evaluator Javina George
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20210928140455
FACILITY NAME:MURRIETA GARDENSFACILITY NUMBER:
331880802
ADMINISTRATOR:NIARE FEASTERFACILITY TYPE:
740
ADDRESS:24200 MONROE AVETELEPHONE:
(951) 600-7676
CITY:MURRIETASTATE: CAZIP CODE:
92562
CAPACITY:72CENSUS: 50DATE:
06/15/2023
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Brittany Kavanaugh, Executive Director TIME COMPLETED:
10:45 AM
ALLEGATION(S):
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***This report was amended on 6/21/23***

Facility did not notify resident's responsible party about injuries.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Javina George made an unannounced visit to the facility to deliver findings for the allegations listed above. LPA met with Executive Director Brittany Kavanaugh and explained the purpose of the visit and elements of the allegations. The investigation consisted of observation, interviews, and record review.

LPA reviewed an incident report completed for resident #1 (R1) and it notes that under notifications Physician-hospice agency was notified on September 17, 2021, Manager on duty was notified on September 17, 2021, and the family was notified on September 20, 2021, three days after the facility staff became aware of R1s injuries. Per interview with Executive Director who became aware of the incident on Saturday September 18, 2021, stated that the facility was still investigating the incident before informing the family as there was no explanation that could be provided as to how R1 obtained the skin tears. LPA reviewed the facility’s Plan of Operations, for procedure Care for properly reporting incidents. The Procedure Care states in part; “15-Internal Incident Report and Unusual Incident Form dated December 15, 2017”; “item #6,
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javina GeorgeTELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:

DATE: 06/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2023
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 18-AS-20210928140455
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: MURRIETA GARDENS
FACILITY NUMBER: 331880802
VISIT DATE: 06/15/2023
NARRATIVE
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Incidents are reported immediately to family/responsible party and Physician. R1’s family came to the facility for a visit and observed the skin tears/scratches, this information had not been reported to the responsible party as noted in the facilities reporting requirements as noted above. Therefore, the allegation of Facility did not notify resident's responsible party about injuries is SUBSTANTIATED. A finding that the complaint is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met.

An exit interview was conducted and a copy of this report, 9099D and appeal rights were provided to Executive Director Brittany Kavanaugh.



SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javina GeorgeTELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:

DATE: 06/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 18-AS-20210928140455
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: MURRIETA GARDENS
FACILITY NUMBER: 331880802
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/15/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/29/2023
Section Cited
CCR
87208(a)(1)
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87208 Plan of Operation
(a)Each facility shall have and maintain a current, written definitive plan of operation. The plan and related materials shall be on file in the facility and shall be submitted to the licensing agency with the license application. Any significant changes in the plan of
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1 out of 1 times, the licensee failed to notify R1’s family immediately about the injuries sustained, as stated in the facility’s plan of operation, this poses a potential health, safety and personal rights risk to persons in care.


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 operation which would affect the services to residents shall be submitted to the licensing agency for approval. The plan and related materials shall contain the following: (1) Statement of purposes and program goals. This requirement is not met as evidenced by:
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The Licensee agrees to conduct and inservice on reporting requirements. Proof of POC is to be submitted to the department by 5pm on the due date indicated.
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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 EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javina GeorgeTELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:

DATE: 06/15/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 5
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
09/28/2021 and conducted by Evaluator Javina George
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20210928140455

FACILITY NAME:MURRIETA GARDENSFACILITY NUMBER:
331880802
ADMINISTRATOR:NIARE FEASTERFACILITY TYPE:
740
ADDRESS:24200 MONROE AVETELEPHONE:
(951) 600-7676
CITY:MURRIETASTATE: CAZIP CODE:
92562
CAPACITY:72CENSUS: 50DATE:
06/15/2023
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Brittany Kavanaugh, Executive Director TIME COMPLETED:
10:45 AM
ALLEGATION(S):
1
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***This complaint report was amended on 6/21/23***

Resident sustained injuries while in care.
Facility did not seek treatment for resident's injuries.
Facility did not notify appropriate agencies of suspected abuse.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Javina George made an unannounced visit to the facility to deliver findings for the allegations (s) listed above. LPA met with Executive Director Brittany Kavanaugh and explained the purpose of the visit and elements of the allegations. The investigation consisted of observation, interviews, and record review.

Resident sustained injuries while in care.
Per the incident report completed on 9/17/21 Resident # 1 (R1) was observed and noted to have two small skin tears with discoloration on their right forearm. Based on observation the skin tears noted look as if (index and middle) fingernails were dug into R1s right forearm. R1 could not recall how they obtained the scratches. Staff became aware of the incident when making their rounds and observed the scratches on Friday September 17, 2021, around 10:00pm. Documentation reviewed note R1 to have frequent skin irritation, a diagnosis of Eczema, and to pick at their scratches on their legs and arms. In addition, LPA reviewed documentation noting that R1 to have some unpredictable behaviors such as having been found with items such as forks, and cups in their diaper when staff change them.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javina GeorgeTELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:

DATE: 06/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 18-AS-20210928140455
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: MURRIETA GARDENS
FACILITY NUMBER: 331880802
VISIT DATE: 06/15/2023
NARRATIVE
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R1 was also noted to be agitated at various times throughout the day and found to be in other resident bedrooms eating their snacks. Interviews conducted with staff all denied hearing of another staff or resident causing physical harm to R1 or causing injuries to R1. It could not be confirmed whether R1s injuries were self-inflicted or caused by someone else. Due to lack of evidence the allegation of Resident sustained injuries while in care is UNSUBSTANTIATED.

Facility did not seek treatment for resident's injuries.
R1 was noted to be observed to have skin tears/scratches on September 17, 2021, around 10:00pm. LPA reviewed the facility resident incident report noting that basic first aid was provided and applied. Per interviews conducted with staff basic first aid administered consisted of cleaning the skin tears/scratches with an alcohol swab and applying Neosporin. A bandage was not provided so that the scratch could air out. LPA also reviewed the facility’s skin tear tracking log, and the skin tears/scratches are noted for R1 and the plan indicated is first aid was provided as required. The allegation of Facility did not seek treatment for residents’ injuries is UNSUBSTANTIATED.

Facility did not notify appropriate agencies of suspected abuse.
The department received an SIR on September 21, 2021, documenting the incident that occurred on September 17, 2021, reporting that R1 had “two small skin tears and the reason, being unknown.” The incident was reported within the required time frame. In addition, LPA reviewed the facility’s Plan of Operations, for procedure Care for properly reporting incidents. The Procedure Care states in part; “15-Internal Incident Report and Unusual Incident Form dated December 15, 2017;” “item #7 All incidents related to physical abuse, neglect, sexual assault, or exploitation are reported to the ombudsman, state licensing agency and in the case of assault (physical or sexual), to law enforcement (refer to Elder Abuse Policy).” Based on interviews conducted, the facility staff did not suspect abuse and reported that R1 could have been picking and scratching their skin as they normally do. Per the previous Executive Director Niare the incident was reported to Community Care Licensing (CCL) in an effort to be proactive, while the facility investigated the incident. Therefore, the allegation of Facility did not notify appropriate agencies of suspected abuse is UNSUBSTANTIATED. A finding that the complaint is UNSUBSTANTIATED means 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, therefore the allegation is unsubstantiated at this time.
An exit interview was conducted, and a copy of this report was provided to Brittany Kavanaugh, Executive Director.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javina GeorgeTELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:

DATE: 06/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5