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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331880905
Report Date: 03/25/2022
Date Signed: 03/25/2022 10:03:24 AM

Unsubstantiated


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: 36DATE:
03/25/2022
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Azizi Baranauskas, Executive Director (ED)TIME COMPLETED:
10:00 AM
ALLEGATION(S):
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Facility is not operating under the licensed facility address.
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.

With regard to the allegation, "Facility is not operating under the licensed facility address," it was alleged Temecula Memory Care is not operating under the licensed facility address: 44280 Campanula Way, Temecula, Ca 92592. On this visit, the LPA observed the Temecula Memory Care premises to be located at the following address: 44320 Campanula Way, Temecula, Ca 92592. According to ED, Baranauskas, both addresses are owned by the Licensee, GHC OF TEM-RCFE, LLC. The LPA observed both buildings were located on the same property. A records review revealed an Application for Community Care Facility or Residential Care Facility for the Elderly License dated 02/25/2020, revealed the first address rather than the former. Therefore, based on records review and the Department's failure to ensure the appropriate address was listed on the application for licensure, this allegation is deemed UNSUBSTANTIATED at this time. A finding that the
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Deborah MullenTELEPHONE: (951) 248-0313
LICENSING EVALUATOR NAME: Stephanie TorresTELEPHONE: (951) 295-3927
LICENSING EVALUATOR SIGNATURE:

DATE: 03/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/25/2022
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 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: 03/25/2022
NARRATIVE
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complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

This report was reviewed with Baranauskas and a copy was provided.
SUPERVISOR'S NAME: Deborah MullenTELEPHONE: (951) 248-0313
LICENSING EVALUATOR NAME: Stephanie TorresTELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:

DATE: 03/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/25/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2