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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331880815
Report Date: 12/21/2022
Date Signed: 12/21/2022 10:55:36 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
, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/17/2021 and conducted by Evaluator Melody Brown
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20211217160328
FACILITY NAME:A TENDER TOUCH SENIOR LIVING LLCFACILITY NUMBER:
331880815
ADMINISTRATOR:MOJICA, FLORENCE AFACILITY TYPE:
740
ADDRESS:1651 ROSE AVENUETELEPHONE:
(310) 532-5338
CITY:BEAUMONTSTATE: CAZIP CODE:
92223
CAPACITY:6CENSUS: 3DATE:
12/21/2022
ANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:LIcensee/Administrator Florence MojicaTIME COMPLETED:
11:30 AM
ALLEGATION(S):
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Facility placed an audio surveillance device in resident's bedroom
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Melody Brown and Michelle Echeverria met with Licensee/Administrator Florence Mojica at Community Care Licensing Division (CCLD) Adult and Senior Care (ASC) Regional Office 12/21/2022 at 10:00 AM to deliver findings for the allegation listed above. LPAs Brown and Echeverria explained the purpose of the requested Office Visit. The investigation consisted of observation, interviews and review of pertinent documentations.

Through the information gathered during the investigation, it was confirmed by documents review and interviews that Facility placed an audio surveillance device in resident's bedroom. Interviews with residents and staff indicated knowledge of the audio surveillance device in resident’s bedroom. During the tour of the facility last 12/21/2021, LPAs Brown and Lama observed audio surveillance device placed in the bedroom of Resident 1 (R1), Resident 2 (R2) and Resident 3 (R3). *** Continuation in LIC9099C ***
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:

DATE: 12/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2022
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-20211217160328
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
, CA 92507
FACILITY NAME: A TENDER TOUCH SENIOR LIVING LLC
FACILITY NUMBER: 331880815
VISIT DATE: 12/21/2022
NARRATIVE
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Licensee/Administrator Mojica reported that if a resident is non-ambulatory, the bedroom has audio surveillance device for the staff to appropriately monitor the non-ambulatory residents in care. Moreover, though Licensee/Administrator Mojica indicated that responsible party of Resident 3 (R3), Resident 1 (R1) and Resident 2 (R2) provided consent on audio surveillance device on R3, R1 and R2's bedroom. Interviews with both R3, R1 and R2's responsible party revealed they both did not provide consent to the audio surveillance device in their family’s bedroom. LPA Brown will be issuing a deficiency for this issue as this pose potential health, safety and personal rights risk to residents in care.

Based on LPAs Brown and Echeverria's observations and interviews, the preponderance of evidence standard has been met, therefore the allegation Facility placed an audio surveillance device in resident's bedrooms found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6 & Chapter 8) is being cited on the attached LIC9099D.

An exit interview was conducted where this report, LIC9099, LIC9099D, and Appeal Rights were discussed and provided to Licensee/Administrator Florence Mojica.

SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:

DATE: 12/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 18-AS-20211217160328
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
, CA 92507

FACILITY NAME: A TENDER TOUCH SENIOR LIVING LLC
FACILITY NUMBER: 331880815
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/21/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/03/2023
Section Cited
CCR
87307(a)
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87307 Personal Accommodations and Services (a) Living accommodations and grounds shall be related to the facility's function. The facility shall be large enough to provide comfortable living accommodations and privacy for the residents… This requirement is not met as evidenced by:
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Licensee stated to train all staff on CCR 87307(a) and will submit Training Log to LPA Brown by POC due date.
Licensee will submit a Statement of Understanding on CCR 87307(a) to LPA Brown by POC due date.
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Based on interview and records review, the Licensee did not comply with the section cited above by placing an audio surveillance device in R3, R2 and R1’s bedroom without R3, R2 and R1’s responsible party’s consent which poses potential health, safety and personal rights risk 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: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:

DATE: 12/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2022
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
, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/17/2021 and conducted by Evaluator Melody Brown
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20211217160328

FACILITY NAME:A TENDER TOUCH SENIOR LIVING LLCFACILITY NUMBER:
331880815
ADMINISTRATOR:MOJICA, FLORENCE AFACILITY TYPE:
740
ADDRESS:1651 ROSE AVENUETELEPHONE:
(310) 532-5338
CITY:BEAUMONTSTATE: CAZIP CODE:
92223
CAPACITY:6CENSUS: 3DATE:
12/21/2022
ANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:LIcensee/Administrator Florence MojicaTIME COMPLETED:
11:30 AM
ALLEGATION(S):
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Resident sustained wounds while in care
Facility did not update resident's records.
Facility did not meet resident's nutritional needs.
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Melody Brown and Michelle Echeverria met with Licensee/Administrator Florence Mojica at Community Care Licensing Division (CCLD) Adult and Senior Care (ASC) Regional Office 12/21/2022 at 10:00 AM to deliver findings for the allegations listed above. LPAs Brown and Echeverria explained the purpose of the requested Office Visit. The investigation consisted of observation, interviews and review of pertinent documentations.

The first allegation indicates Resident sustained wounds while in care. Staff interviews indicated that R3 did not have wounds except for the skin tear when the hospice staff was giving R3 a shower. Interviews with staffs revealed that on 10/04/2021, Hospice staff arrived at the facility to shower R3 but that day, R3 was weak and hospice staff unable to give R3 a shower and R3 fell and Staff 2 (S2) reported that they heard hospice staff shouted for help at the shower and S2 and S4 assisted R3 to the shower chair and they noticed a skin tear on R3's right arm. ***Continuation on LIC9099C***
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:

DATE: 12/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2022
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-20211217160328
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
, CA 92507
FACILITY NAME: A TENDER TOUCH SENIOR LIVING LLC
FACILITY NUMBER: 331880815
VISIT DATE: 12/21/2022
NARRATIVE
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Moreover, per LPA Brown's review of Hospice Care Notes, incident last 10/04/2021 was reported to hospice and R3 was assessed, being treated for wound care and wound was reported to R3's physician. LPA Brown also noted R3's Weekly Progress Report on R3's wound care.

The second allegation indicates facility did not update resident's records. Staff interviews and documents review indicated residents’ records were all updated by Licensee/Administrator Mojica. LPA Brown reviewed R3’s records during the visit last 12/21/2021 and LPA Brown observed that R3’s records were all current and updated at the facility by Licensee/Administrator Mojica.

The third allegation indicates facility did not meet residents’ nutritional needs. Interviews with residents and staffs and documents review indicated residents were served healthy breakfast, lunch, dinner and snacks. In addition, interviews with staffs and residents revealed that adequate meals were always served and on time. Also, during LPAs Brown and Lama's tour of the facility last 12/21/2021, adequate supply of perishable (more than three (3) days) and non-perishable foods (more than seven (7) days) were observed.

Based on interviews and records review, the allegation Resident sustained wounds while in care (Allegation #1), facility did not update resident records (Allegation #2), facility did not meet residents’ nutritional needs (Allegation #3), are UNSUBSTANTIATED. A finding of unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur.



An exit interview was conducted, where this report (LIC9099) was discussed and provided to Licensee/Administrator Florence Mojica.
SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:

DATE: 12/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 5