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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331880905
Report Date: 03/29/2022
Date Signed: 03/29/2022 03:38:22 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
03/22/2022 and conducted by Evaluator Crystal Colvin
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20220322170112
FACILITY NAME:TEMECULA MEMORY CAREFACILITY NUMBER:
331880905
ADMINISTRATOR:GEDDIE, JAMESFACILITY TYPE:
740
ADDRESS:44320 CAMPANULA WAYTELEPHONE:
(951) 428-4990
CITY:TEMECULASTATE: CAZIP CODE:
92592
CAPACITY:64CENSUS: 36DATE:
03/29/2022
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Azizi Baranauskas - Executive Director (ED)TIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Staff do not assist resident with obtaining medical care

Facility did not safeguard resident's personal property
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Crystal Colvin arrived at the facility unannounced in order to initiate an investigation of a complaint with the above allegation(s). LPA identified herself and discussed the purpose of the visit and the elements of the allegation(s) with Executive Director Azizi Baranauskas. Below is a summary of the findings of this complaint:

Regarding allegation "Staff do not assist resident with obtaining medical care": LPA Colvin reviewed facility records for resident (R1), including Physician's Report, Staff Notes, Special Incident Report (SIR) dated 3/23/22, Power of Attorney paperwork, and records from medical visits since admission to the facility. LPA Colvin observed that on multiple occasions R1 has requested medical attention, but facility staff either failed to assist R1 with making an appointment or going to Urgent Care/Emergency Room, or staff directly interfered with R1's attempt to get medical care. On 3/22/22, R1 informed facility staff that they had been wheezing and coughing and would like an X-ray to check their lungs. Staff documented that they did not observe any wheezing or coughing and that they would monitor the resident's condition.
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: 03/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2022
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 6
Control Number 18-AS-20220322170112
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: TEMECULA MEMORY CARE
FACILITY NUMBER: 331880905
VISIT DATE: 03/29/2022
NARRATIVE
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As of today’s, inspection, there are no noted regarding scheduling an X-ray to be completed for R1, nor an appointment with R1's doctor to discuss R1's concerns. Executive Director Azizi Baranauskas stated that the staff contacted R1's doctor and the doctor stated to monitor R1's condition. Additionally, LPA Colvin observed in staff notes that on both 3/6/22 & 3/23/22, R1 called 911 in order to attempt to get medical attention, and on both occasions, staff spoke with 911 dispatcher and informed them that R1 did not need assistance. Moreover, on 3/23/22, according to SIR submitted by the facility, while R1 was on the phone with 911, "nurse was on the phone to cancel 911 due to non-emergent matter". It should be noted that R1 has a Power of Attorney (POA), though the documents provided to LPA Colvin for the POA are limited to that of POA of estate, and not medical. Therefore, R1 retains the right to make decisions about their own medical care, including going to the Emergency Room via 911. Additionally, regardless of a POA, facility staff are not permitted to "cancel" a 911 call from a resident, as that is an interference with the residents' communications. Therefore, based on record review, the allegation "Staff do not assist resident with obtaining medical care" is SUBSTANTIATED.

Regarding allegation "Facility did not safeguard resident's personal property": LPA Colvin interviewed staff, resident(s), and other relevant parties, as well as reviewed the facility's file for R1. LPA Colvin inquired with Executive Director Azizi Baranauskas regarding R1's reported missing items, including an "Alexa" machine. Azizi stated that they have no knowledge of R1 missing or owning an Alexa machine. LPA Colvin requested a copy of the items owned by R1 upon move in from the Assistant Administrator, and was informed that the facility does not require the resident or their family to provide an itemized list, and the facility staff do not review all of the residents' belongings themselves upon move-in. LPA Colvin confirmed through interviews that R1 did in fact own an "Alexa" and that it has not been observed in R1's room within the last week. It is additionally relevant to note that staff frequently clean R1's room and remove items they deem not to belong to R1, as stated in both interviews and in Staff Notes.

The facility is responsible for providing safeguards for residents' property if they are incapable of protecting or looking after their own property. In R1's Physician's Report, it is marked that R1 is not able to manage their own cash resources. Therefore, the facility should take measures to be familiar with what property R1 has in the facility, so that they can be aware if the item goes missing or is stolen. The facility has not taken these measures, as observed by Executive Director Azizi Baranauskas' lack of knowledge of R1's property. Therefore, based on record review and interviews, the allegation "Facility did not safeguard resident's personal property" is SUBSTANTIATED.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Crystal ColvinTELEPHONE: (951) 204-0848
LICENSING EVALUATOR SIGNATURE:

DATE: 03/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 6
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
03/22/2022 and conducted by Evaluator Crystal Colvin
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20220322170112

FACILITY NAME:TEMECULA MEMORY CAREFACILITY NUMBER:
331880905
ADMINISTRATOR:GEDDIE, JAMESFACILITY TYPE:
740
ADDRESS:44320 CAMPANULA WAYTELEPHONE:
(951) 428-4990
CITY:TEMECULASTATE: CAZIP CODE:
92592
CAPACITY:64CENSUS: DATE:
03/29/2022
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Azizi Baranauskas - Executive Director (ED)TIME COMPLETED:
03:00 PM
ALLEGATION(S):
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9
Residents not provided with sufficient food service

Staff speaks rudely to resident
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Crystal Colvin arrived at the facility unannounced in order to initiate an investigation of a complaint with the above allegation(s). LPA identified herself and discussed the purpose of the visit and the elements of the allegation(s) with Executive Director Azizi Baranauskas. Below is a summary of the findings of this complaint:

Regarding allegation "Residents not provided with sufficient food service": LPA Colvin conducted interviews with staff and residents as well as observed the serving of one meal (lunch) during today's inspection. LPA Colvin confirmed that lunch today was served at approximately the scheduled time (12:30pm), and that measures are taken by the facility to ensure proper temperature for the food (temperature taken at cooking site & food kept at safe temperature once it arrives and until served). Additionally, the facility has a microwave which they can use to reheat the residents' food if it has become too cold while they wait to eat. There is not enough evidence available to suggest that the facility does not provide meal services in a timely manner, or that the food is not at an appropriate temperature when provided to the residents.
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: 03/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2022
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 6
Control Number 18-AS-20220322170112
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: TEMECULA MEMORY CARE
FACILITY NUMBER: 331880905
VISIT DATE: 03/29/2022
NARRATIVE
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Therefore, based on observations and interviews, the allegation of "Residents not provided with sufficient food service" is UNSUBSTANTIATED.

Regarding allegation "Staff speaks rudely to resident": LPA Colvin conducted interviews with staff and residents, as well as reviewed Staff Notes for one resident (R1). LPA Colvin observed that R1 is often redirected by staff for purposes of ensuring R1's safety (R1 standing on furniture to reach an item), or to attempt to prevent/discourage R1 from dialing 911 for non-emergent issues. There is not enough evidence to support the allegation of staff speaking rudely to residents, therefore the allegation 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 Executive Director Azizi Baranauskas 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: 03/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 18-AS-20220322170112
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: TEMECULA MEMORY CARE
FACILITY NUMBER: 331880905
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/29/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
03/30/2022
Section Cited
CCR
87468.1(a)(16)
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Personal Rights of Residents in All Facilities: (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (16) To receive or reject medical care or other services. This requirement was not met as evidenced by:
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Licensee agrees to review Personal Rights of Residents with all staff and educate them on residents' rights to contact 911. This may be done through an all-staff meeting or training. Licensee to provide LPA Colvin with proof of all-staff meeting or training, including all staff's names, signatures, and date.
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Based on interviews and record review, the Licensee did not comply with the above regulation with at least one resident (R1). LPA Colvin confirmed that on at least one occasion (3/23/22) facility staff contacted 911 in order to "cancel" R1's call to 911. This is an immediate personal rights violation of R1.
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Licensee to provide this by Plan of Correction date of 3/30/22.
Request Denied
Type A
03/30/2022
Section Cited
CCR
87648.2(a)(25)
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Additional Personal Rights...in Privately Operated Facilities: (a) In addition to the rights listed...residents...shall have all of the following personal rights: (25) To protection of their property from theft or loss according to Health and Safety Code... This requirement was not met as evidenced by:
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Licensee agrees to review facility's Plan of Operation and formulate a plan for how the facility will make efforts to ensure residents' property is kept safe, or to verify presence of residents' property in case it is missing/stolen. Licensee to provide LPA Colvin with addendum to Plan of Operator by the Plan of Correction
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Based on interviews and record review, the Licensee did not comply with the above regulation with at least one item (Alexa). R1 reports that their Alexa was stolen/missing. Executive Director has no knowledge of R1's property, as no list is maintained at the facility. This is an immediate personal rights violation.
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date of 3/30/22.
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: 03/29/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 18-AS-20220322170112
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: TEMECULA MEMORY CARE
FACILITY NUMBER: 331880905
VISIT DATE: 03/29/2022
NARRATIVE
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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 deficiency was 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 Executive Director Azizi Baranauskas during the exit interview.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Crystal ColvinTELEPHONE: (951) 204-0848
LICENSING EVALUATOR SIGNATURE:

DATE: 03/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2022
LIC9099 (FAS) - (06/04)
Page: 6 of 6