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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331881008
Report Date: 10/28/2023
Date Signed: 10/28/2023 12:08:46 PM

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
03/24/2021 and conducted by Evaluator Bernadette Allen
COMPLAINT CONTROL NUMBER: 18-AS-20210324090309
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:0CENSUS: 0DATE:
10/28/2023
UNANNOUNCEDTIME BEGAN:
09:25 AM
MET WITH:Heather Acosta-Support StaffTIME COMPLETED:
12:30 PM
ALLEGATION(S):
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Facility staff took away a resident's walker.
Facility staff took away a resident's clothing of choice.
Facility staff did not provide a copy of the admission agreement to the resident's representative.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Bernadette Allen conducted an unannounced visit to deliver findings for the mentioned allegations. LPA Allen met with Heather Acosta who was informed of the purpose of the visit.

LPA Allen conducted interviews with residents, resident’s responsible parties and staff members.
The interviews conducted with six (6) staff members, two (2) residents, and four (4) responsible parties have all stated staff members have never taken away their walkers or any equipment used for ambulating, they have all stated they are allowed to wear clothing of their choice and if they wanted to obtain or see copies of the residents file they would be allowed to at any time.

Based on the interviews conducted with staff, residents, and responsible parties the above allegations are Unsubstantiated. A finding of unsubstantiated means although the allegations may have happened or is
valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 836-2784
LICENSING EVALUATOR NAME: Bernadette AllenTELEPHONE: (951) 897-2618
LICENSING EVALUATOR SIGNATURE:

DATE: 10/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2023
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-20210324090309
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
VISIT DATE: 10/28/2023
NARRATIVE
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An exit interview was conducted with Heather Acosta and a copy of the report was provided with appeal rights at the conclusion of the visit.
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 836-2784
LICENSING EVALUATOR NAME: Bernadette AllenTELEPHONE: (951) 897-2618
LICENSING EVALUATOR SIGNATURE:

DATE: 10/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2