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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331881008
Report Date: 10/08/2021
Date Signed: 05/10/2023 01:37:22 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
10/05/2021 and conducted by Evaluator Jesse Gardner
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20211005081414
FACILITY NAME:WINE COUNTRY ASSISTED LIVINGFACILITY NUMBER:
331881008
ADMINISTRATOR:SCHNEIDER, ELVIRAFACILITY TYPE:
740
ADDRESS:5 SHASTA LAKE DRTELEPHONE:
(818) 277-0403
CITY:RANCHO MIRAGESTATE: CAZIP CODE:
92270
CAPACITY:6CENSUS: 5DATE:
10/08/2021
UNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Elvira Schneider, LicenseeTIME COMPLETED:
12:10 PM
ALLEGATION(S):
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Licensee did not have a complete admission agreement for the resident
Licensee did not issue a refund
Licensee did not keep resident's medical information confidential
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Jesse Gardner arrived at the facility and met with Licensee Elvira Schneider. LPA Gardner advised Ms. Schneider regarding the purpose of the visit, and the above allegations. Ms. Schneider does not have a copy of the admissions agreement, and has a no refund policy in place. Ms. Schneider also indicated that a past caretaker of hers mistakenly mixed records together allowing that record to leave the facility. Based on interviews conducted with RP, and Licensee, the above allegations are SUBSTANTIATED. A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.
Substantiated
Estimated Days of Completion: 0
SUPERVISOR'S NAME: Deborah MullenTELEPHONE: (951) 248-0341
LICENSING EVALUATOR NAME: Jesse GardnerTELEPHONE: (951) 205-2683
LICENSING EVALUATOR SIGNATURE:

DATE: 10/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2021
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 3
Control Number 18-AS-20211005081414
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: WINE COUNTRY ASSISTED LIVING
FACILITY NUMBER: 331881008
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/08/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/22/2021
Section Cited
CCR
87506(b)(15)
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87506 Resident Records
(b) Each resident’s record shall contain at least the following information:
(15) The admission agreement and pre-admission appraisal, specified in Sections 87507, Admission Agreements and 87457, Pre-admission Appraisal.
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Licensee will ensure each record has an admissions agreement, and submit a memorandum of understanding of the following regulation by 10/22/21.
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This requirement was not being met as evidenced by: Through interviews obtained, this poses a potential health and safety 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: Reyna LaceyTELEPHONE: (951) 248-0341
LICENSING EVALUATOR NAME: Jesse GardnerTELEPHONE: (951) 205-2683
LICENSING EVALUATOR SIGNATURE:

DATE: 10/08/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 18-AS-20211005081414
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: WINE COUNTRY ASSISTED LIVING
FACILITY NUMBER: 331881008
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/08/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/09/2021
Section Cited
CCR
87507(g)(c)(1)
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87507 Admission Agreements
(g) Admission agreements shall specify the following:
(5) Refund conditions.
(E) Preadmission fees shall be refunded...



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Licensee will draft a new admissions agreement to comply with Title 22 and review the regulation, and agrees to provide the applicable refund amount of the preadmission fee to R1. Licensee to provide LPA Gardner with proof of refund. Proof requested is due by Plan of Correction date of 10/9/21.
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1. A 100 percent refund of a preadmission fee shall be provided to an applicant...
b. The licensee fails to provide full written disclosure of preadmission fee charges and refund conditions. This requirement was not being met as evidenced by: Through interviews obtained, this poses an immediate risk to residents in care.
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Type A
10/09/2021
Section Cited
CCR
87506(c)(1)
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87506 Resident Records
(c) All information and records obtained from or regarding residents shall be confidential.


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Licensee agrees to have applicable staff re-trained on record keeping. Licensee to provide LPA Gardner with proof of training by Plan of Correction date of 10/8/21.
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(1) The licensee shall be responsible for storing active and inactive records and for safeguarding the confidentiality of their contents. The licensee and all employees shall reveal or make available confidential information only upon the resident's written consent or that of his designated representative.
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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: Reyna LaceyTELEPHONE: (951) 248-0341
LICENSING EVALUATOR NAME: Jesse GardnerTELEPHONE: (951) 205-2683
LICENSING EVALUATOR SIGNATURE:

DATE: 10/08/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 3