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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331880809
Report Date: 11/17/2021
Date Signed: 11/17/2021 01:39:29 PM

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
11/10/2021 and conducted by Evaluator Crystal Colvin
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20211110100838
FACILITY NAME:ABOUNDING GRACE CARE HOME, INC.FACILITY NUMBER:
331880809
ADMINISTRATOR:DELA CRUZ, CHERYLFACILITY TYPE:
740
ADDRESS:26152 WINDEMERE WAYTELEPHONE:
(951) 961-1303
CITY:MORENO VALLEYSTATE: CAZIP CODE:
92555
CAPACITY:6CENSUS: 4DATE:
11/17/2021
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Aurora Cuasay - StaffTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Resident's medical needs not being met

Resident not being given medication as prescribed
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Crystal Colvin and Venus Mixon arrived at the facility unannounced in order to initiate an investigation of a complaint with the above allegation(s). LPAs identified themselves and discussed the purpose of the visit and the elements of the allegation(s) with Staff Aurora Cuasay. Below is a summary of the complaint investigation findings:

Regarding allegation "Resident's medical needs not being met": LPAs Colvin and Mixon reviewed resident and staff files during today's inspection, as well as conducted a tour of the facility. LPAs observed a Hoyer Lift in the facility, which staff Aurora confirmed is utilized for multiple residents, including Resident 1 (R1). LPAs asked for staff files for the two other caregivers present at the facility today (S1 & S2), and was informed that there is no file for either caregiver. LPA Colvin inquired about records on staff training, and Aurora stated that there are no training records for either. LPA Colvin additionally learned that S1 takes R1's blood pressure daily, but has no training. Since staff does not have training on how to use equipment in the facility neccesary for residents' care, but are using it anyway, residents are at risk for improper application of the equipment.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Crystal ColvinTELEPHONE: (951) 204-0848
LICENSING EVALUATOR SIGNATURE:

DATE: 11/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2021
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-20211110100838
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: ABOUNDING GRACE CARE HOME, INC.
FACILITY NUMBER: 331880809
VISIT DATE: 11/17/2021
NARRATIVE
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Staff are not qualified to utilize the equipment necessary for R1's care, therefore, the allegation "Resident's medical needs not being met" is SUBSTANTIATED.

Regarding allegation "Resident not being given medication as prescribed": LPAs Colvin and Mixon reviewed the medication and medication records for R1 and observed that while R1 is prescribed over 10 medications, only 5 medications were present at the facility. Staff Aurora stated that R1 has been out of these medications and is waiting for R1 to coordinate with their doctor regarding refills. LPA Colvin additionally observed documentation in a staff notebook for residents which detailed several medications which were not administered to R1 on 11/14/21. Therefore, based on observations and record review, the allegation of "Resident not being given medication as prescribed" is SUBSTANTIATED.

A finding that the complaint is SUBSTANTIATED means that the allegation(s) is valid because the preponderance of the evidence standard has been met.

Due to observations made by LPA Colvin, the facility was cited, and deficiencies were noted on LIC 9099 D. An exit interview was conducted where this report and appeal rights were discussed. A copy this report, LIC 9099D, and appeal rights were provided to staff Aurora Cuasay during the exit interview.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Crystal ColvinTELEPHONE: (951) 204-0848
LICENSING EVALUATOR SIGNATURE:

DATE: 11/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 18-AS-20211110100838
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: ABOUNDING GRACE CARE HOME, INC.
FACILITY NUMBER: 331880809
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/17/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/18/2021
Section Cited
CCR
87411(a)
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Personnel Requirements - General: (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs... This requirement was not met by:
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Licensee agreed to have all staff providing care to residents trained on aspects related to the residents' needs. Proof of training to be provided to LPA Colvin by Plan of Correction date of 11/18/21.
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Based on record review and interviews, the Licensee did not comply with the above regulation with at least two staff. LPAs observed that S1 & S2 did not have any documented training, but assisted residents with Hoyer Lift and checking blood pressure. This is an immediate safety risk to residents.
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Type A
11/18/2021
Section Cited
CCR
87464(f)(4)
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Basic Services: (f) Basic services shall at a minimum include: (4) Personal assistance and care as needed by the resident...such as...assistance with taking prescribed medications... This requirement was not met by:
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Licensee agrees to coordinate with R1's prescribing physician(s) and pharmacy to ensure that all of R1's medciations are filled and are available at the facility for staff to administer to R1. Licensee to provide LPA Colvin with list of R1's medication and status of fulfillment of medication and when it should be
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Based on record review and interview, the Licensee did not comply with the above regulation with at least one resident (R1). LPAs learned that R1 is out of multiple medications and several medications were not been administered to R1 on 11/14/21. This is an immediate health risk to R1.
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available at the facility. Licensee to additionally review Title 22 Regulation Section 87464 regarding Basic Services provide LPA Colvin with a Statement of Understanding of facility's duties to provide care to residents. List/Update on medication and Statement due by Plan of Correction date of 11/18/21.
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: Crystal ColvinTELEPHONE: (951) 204-0848
LICENSING EVALUATOR SIGNATURE:

DATE: 11/17/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2021
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
11/10/2021 and conducted by Evaluator Crystal Colvin
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20211110100838

FACILITY NAME:ABOUNDING GRACE CARE HOME, INC.FACILITY NUMBER:
331880809
ADMINISTRATOR:DELA CRUZ, CHERYLFACILITY TYPE:
740
ADDRESS:26152 WINDEMERE WAYTELEPHONE:
(951) 961-1303
CITY:MORENO VALLEYSTATE: CAZIP CODE:
92555
CAPACITY:6CENSUS: 4DATE:
11/17/2021
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Aurora Cuasay - StaffTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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9
Staff does not provide resident a safe method to transfer
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Crystal Colvin and Venus Mixon arrived at the facility unannounced in order to initiate an investigation of a complaint with the above allegation(s). LPAs identified themselves and discussed the purpose of the visit and the elements of the allegation(s) with Staff Aurora Cuasay. Below is a summary of the complaint investigation findings:

Regarding allegation "Staff does not provide resident a safe method to transfer": LPAs Colvin and Mixon toured the faciity and observed numerous devices to aid with mobility of residents, such as cammodes, Hoyer Lift, shower chair, etc. LPAs interviewed staff Aurora regarding how residents' toileting needs are met, as most of the residents in the facility appeared to have mobiity issues. Aurora informed LPAs that most of the residents are able to transfer with minimal assistance from staff, with the exception of one resident (R1), who needs a Hoyer Lift. Aurora reported that all of R1's care since their admission to the facility on 11/3/21 has been in bed, as R1 has not requested to be transported to the shower or toilet for care. LPA Colvin attempted to interview R1 via telephone, as R1 was out at a doctor's appointment, but was unable to get a hold of R1.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Crystal ColvinTELEPHONE: (951) 204-0848
LICENSING EVALUATOR SIGNATURE:

DATE: 11/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2021
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-20211110100838
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: ABOUNDING GRACE CARE HOME, INC.
FACILITY NUMBER: 331880809
VISIT DATE: 11/17/2021
NARRATIVE
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LPAs had Aurora utilize all mobility equipment in the master bedroom (R1's room) and bathroom, where R1 would receive the care and be transferred if requested. LPAs observed that while the space in the bathroom is tight, staff Aurora was able to maneuver the Hoyer Lift over to a rolling shower chair, which doubles as chair for over the toilet seat. LPAs additionally observed Aurora move the Hoyer Lift over to the bath tub, where she stated two staff would assist R1 with transfer to the chair that remains in the tub. LPAs observed that this maneuver would be more difficult, due to R1 needing two person assist. Aurora additionally showed that R1 could be moved from a wheelchair to the shower chair inside the secondary bathroom, with two staff assistance and a sliding board. LPA Colvin requested to see the sliding board, but Aurora stated the facility does not have one on hand, though she has requested one from Home Health. Based on facility staff's demonstration of use of mobility devices as well as R1's care being provided for in bed at this time, the allegation of "Staff does not provide resident a safe method to transfer" is UNSUBSTANTIATED.

A finding of 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.

An exit interview was conducted with staff Aurora Cuasay and a copy of this report was provided.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Crystal ColvinTELEPHONE: (951) 204-0848
LICENSING EVALUATOR SIGNATURE:

DATE: 11/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 5