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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331881130
Report Date: 03/27/2023
Date Signed: 03/27/2023 03:51:12 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
03/22/2023 and conducted by Evaluator Jesse Gardner
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20230322134341
FACILITY NAME:C & M COMFORT HOMEFACILITY NUMBER:
331881130
ADMINISTRATOR:COURT, CHRISTIANFACILITY TYPE:
735
ADDRESS:24662 MANTEE PLACETELEPHONE:
(951) 378-5820
CITY:MORENO VALLEYSTATE: CAZIP CODE:
92553
CAPACITY:6CENSUS: 4DATE:
03/27/2023
UNANNOUNCEDTIME BEGAN:
02:21 PM
MET WITH:Christian Court, AdministratorTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Facility staff member is not allowing resident to return to the facility after a hospitalization.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Jesse Gardner arrived unannounced at the facility to commence a complaint investigation for the allegation listed above. LPA Gardner identified himself and discussed the purpose of the visit and the elements of the allegation with Administrator Christian Court (S1).

LPA toured the facility, reviewed records, and conducted staff interviews. It was alleged that S1 stated Resident 1 (R1) was not to return from the hospital. Staff interviews revealed that on March 14, 2023 - R1's doctor saw them and stated that their condition was manageable.

**Continued on LIC9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Deborah Mullen
LICENSING EVALUATOR NAME: Jesse Gardner
LICENSING EVALUATOR SIGNATURE:

DATE: 03/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2023
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 3
Control Number 18-AS-20230322134341
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: C & M COMFORT HOME
FACILITY NUMBER: 331881130
VISIT DATE: 03/27/2023
NARRATIVE
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On March 20, 2023, R1 seemed "out of it", and was not able to feed/drink themselves. On March 21, 2023, R1 was transported to the Emergency Room for evaluation. S1 asked the hospital if an assessment had been done for a potential change in condition for R1, in which, according to S1, had not been done. S1 admitted that hospital staff contacted S1 to advise that R1 had been discharged and was ready for pickup around 5pm. R1 remained at the hospital, and later that evening, S1 stated that they were contacted by a hospital worker and was advised that R1 was being evaluated by another medical team. S1 did not pick up R1 when R1 was ready for pickup due to S1's initial feeling that R1 needed further treatment. Therefore, this allegation was Substantiated. A finding that the complaint is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met.

An exit interview was conducted where a copy of this report was discussed with and provided along with copies of the LIC9099-C, LIC811, and Appeal Rights.


SUPERVISORS NAME: Deborah Mullen
LICENSING EVALUATOR NAME: Jesse Gardner
LICENSING EVALUATOR SIGNATURE:

DATE: 03/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 18-AS-20230322134341
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: C & M COMFORT HOME
FACILITY NUMBER: 331881130
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/27/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/28/2023
Section Cited
CCR
80072(a)(3)
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Personal Rights: (a) Except for children’s residential facilities, each client shall have personal rights which include, but are not limited to, the following: (3) To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse, or other actions of a punitive nature, including but not limited to: interference with the daily living functions, including eating, sleeping, or toileting; or withholding of shelter, clothing, medication or aids to physical functioning. This requirement was not being met as evidenced by:
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Licensee agrees to immediately contact Riverside University Health System and have R1 return to the facility. Licensee further agrees to conduct in-service training on Personal Rights and submit the training to LPA by POC date.
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Based on LPA interview with S1, S1 indicated that R1's change of condition had not been identified with an assessment and S1 was not prepared to take R1 back into their facility. This poses an immediate personal rights 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.
SUPERVISORS NAME: Deborah Mullen
LICENSING EVALUATOR NAME: Jesse Gardner
LICENSING EVALUATOR SIGNATURE:

DATE: 03/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3