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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331880905
Report Date: 09/02/2021
Date Signed: 03/25/2022 09:58:38 AM

Unfounded


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
08/27/2021 and conducted by Evaluator Stephanie Torres
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20210827130537
FACILITY NAME:TEMECULA MEMORY CAREFACILITY NUMBER:
331880905
ADMINISTRATOR:GEDDIE, JAMESFACILITY TYPE:
740
ADDRESS:44280 CAMPANULA WAYTELEPHONE:
(951) 428-4990
CITY:TEMECULASTATE: CAZIP CODE:
92592
CAPACITY:64CENSUS: 25DATE:
09/02/2021
UNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Azizi Baranauskas, Executive Director (ED)TIME COMPLETED:
01:10 PM
ALLEGATION(S):
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Staff not providing authorized representative with resident’s medical records in a timely manner.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Stephanie Torres, conducted an unannounced visit to the facility to initiate the investigation into the above allegations. The LPA was met by Executive Director (ED), Azizi Baranauskas, and informed her of the purpose of her visit.

Regarding the allegation, "Staff not providing authorized representative with resident’s medical records in a timely manner," it was alleged Resident One's (R1's) authorized representative requested records from the facility on August 07, 2021 and did not receive copies in a timely manner. The LPA conducted staff interviews, reviewed records, and took copies of pertinent documentation. Interviews and a copy of a text message revealed R1's authorized representative requested records on August 07, 2021. Interviews revealed one staff member, who was responsible for processing records requests, was unavailable from August 03, 2021 until August 15, 2021. Interviews and a check revealed requested copies were provided on August 18, 2021, following S1's return to the facility. Therefore, based on interviews and records revealing S1 was unavailable to provide the
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Deborah MullenTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Stephanie TorresTELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:

DATE: 09/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/02/2021
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 2
Control Number 18-AS-20210827130537
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: 09/02/2021
NARRATIVE
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records, this allegation is deemed UNFOUNDED at this time. A finding that the complaint is unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis.

This report was reviewed with Baranauskas and a copy was provided.
SUPERVISOR'S NAME: Deborah MullenTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Stephanie TorresTELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:

DATE: 09/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/02/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 2