331881187-4-19-2023-56-AS-EMAN-CR4P9H-20230421110711

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 331881187
Report Date: 04/19/2023
Date Signed: 04/19/2023 10:54:09 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 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
03/30/2023 and conducted by Evaluator Ryan Gardner

PUBLIC

COMPLAINT CONTROL NUMBER: 56-AS-20230330130848

FACILITY NAME:	SHAFFER SENIOR CARE, LLC		FACILITY NUMBER:	331881187
ADMINISTRATOR:	SHALABI, JAMAL		FACILITY TYPE:	740
ADDRESS:	672 SHAFFER STREET		TELEPHONE:	(337) 244-2252
CITY:	CORONA	STATE: CA	ZIP CODE:	92879
CAPACITY:	6	CENSUS: 5	DATE:	04/19/2023
		UNANNOUNCED	TIME BEGAN:	09:38 AM
MET WITH:	Jamal Shalabi- Administrator		TIME COMPLETED:	11:05 AM

ALLEGATION(S):

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Staff did not ensure that resident followed dietary guidelines ordered by his physician.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Ryan Gardner made an unannounced visit to the facility to investigate and issue findings for the allegation listed above. LPA stated the purpose of the visit and was granted entry and met with Administrator Jamal Shalabi. The visit consisted of interviews and document review.

For allegation, Staff did not ensure that resident followed dietary guidelines ordered by his physician:

It was alleged that R1 was leaving the facility on their own and purchasing food outside of their dietary guidelines ordered by their doctor.

LPA attempted to interview R1 during the visit. R1 moved out of the facility on 4/14/23.

During document review, LPA reviewed R1’s Physician Report that indicated R1 was able to leave the facility on their own without the assistance of staff.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 248-8222
LICENSING EVALUATOR NAME: Ryan Gardner	TELEPHONE: (951) 836-3180
LICENSING EVALUATOR SIGNATURE:	DATE: 04/19/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/19/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 56-AS-20230330130848

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: SHAFFER SENIOR CARE, LLC	FACILITY NUMBER: 331881187
	VISIT DATE: 04/19/2023

NARRATIVE

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LPA reviewed written statements signed by R1 stating they were refusing to eat meals at the facility, and they understood by doing so they were choosing to not follow their doctors’ orders. R1 also signed a written statement acknowledging that they were aware they needed to make changes in their diet due to their medical condition. R1 acknowledged they were choosing to go against the advice of medical providers and caregivers which could cause health problems. LPA reviewed the facilities monthly menu that includes a variety of healthy food choices.

During interviews staff, staff informed LPA that R1 would often refuse to eat the meals prepared by the facility. R1 chose to leave the facility on their own and purchase alternative food. R1 would often purchase fast food that they either ate while they were out of the facility, or they would bring food back to their bedroom and hide it from staff. Staff tired to include R1 in the meal preparation by having R1 write down a list of food preferences. Staff used R1’s list of food preferences along with R1’s dietary needs to create meals that were within R1’s dietary restrictions. R1 was still not interested in eating the food at the facility.

During interview with R1’s social worker (R1SW), LPA was informed that R1SW knew that R1 was choosing to make unhealthy dietary choices that were affecting R1’s health condition. R1SW informed LPA that the facility and the social worker team were doing their best to educate and help R1 make better choices regarding the food they were consuming. R1SW stated that R1 was choosing to use their personal rights to not follow the doctors ordered dietary guidelines.

Based on evidence obtained, the allegation listed above is deemed UNSUBSTANTIATED. A finding that the complaint is UNSUBSTANTIATED means although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur.

During today’s visit, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations.

An exit interview was conducted, and this report (LIC9099) was discussed and provided to Administrator Jamal Shalabi, along with a copy of the appeal rights.

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 248-8222
LICENSING EVALUATOR NAME: Ryan Gardner	TELEPHONE: (951) 836-3180
LICENSING EVALUATOR SIGNATURE:	DATE: 04/19/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/19/2023

LIC9099 (FAS) - (06/04)

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