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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331881201
Report Date: 11/21/2022
Date Signed: 11/21/2022 01:20:00 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
11/16/2022 and conducted by Evaluator Jesse Gardner
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20221116155439
FACILITY NAME:CONCEPT FOR LIFE HOME LLCFACILITY NUMBER:
331881201
ADMINISTRATOR:DUPREE, TIFFANYFACILITY TYPE:
735
ADDRESS:25791 FIR AVETELEPHONE:
(323) 921-8391
CITY:MORENO VALLEYSTATE: CAZIP CODE:
92553
CAPACITY:4CENSUS: 4DATE:
11/21/2022
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Devin Williams, House ManagerTIME COMPLETED:
01:30 PM
ALLEGATION(S):
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Facility staff did not seek medical attention for resident in a timely manner
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Jesse Gardner made an unannounced visit to initiate an investigation into the above allegation. LPA met with House Manager Devin Williams (S1) and toured the facility. LPA found that on today's visit, there are 2 residents inside the facility, with 2 at their day program.

It was alleged that staff failed to seek timely medical attention for Resident One (R1). LPA conducted interviews with staff and residents and reviewed documentation. Interviews revealed that on November 11, 2022, R1 alerted staff that they were experiencing pain in relation to a possible UTI and not able to urinate for approximately 3-4 days prior.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Deborah Mullen
LICENSING EVALUATOR NAME: Jesse Gardner
LICENSING EVALUATOR SIGNATURE:

DATE: 11/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2022
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 4
Control Number 18-AS-20221116155439
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: CONCEPT FOR LIFE HOME LLC
FACILITY NUMBER: 331881201
VISIT DATE: 11/21/2022
NARRATIVE
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Staff contacted R1's primary doctor, and made an appointment for November 14, 2022. During which time, R1 experienced ongoing pain. Staff did not seek medical attention during this time. Concluding the appointment on November 14, 2022, R1 refused to obtain a catheter from their doctor. R1 was seen at the Emergency Room on November 15, 2022 due to continued pain. R1 received catheter at this point, and was discharged.

Thus the allegation of "Facility staff did not seek medical attention for resident in a timely manner" is SUBSTANTIATED. A finding that the complaint is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met.

The Licensee was issued a citation per Title 22 CCR 80075(a).

An exit interview was conducted where a copy of this report was discussed with and provided along with copies of the LIC811, LIC9099C, LIC9099D, and Appeal Rights.
SUPERVISORS NAME: Deborah Mullen
LICENSING EVALUATOR NAME: Jesse Gardner
LICENSING EVALUATOR SIGNATURE:

DATE: 11/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 4
Control Number 18-AS-20221116155439
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: CONCEPT FOR LIFE HOME LLC
FACILITY NUMBER: 331881201
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/21/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/05/2022
Section Cited
CCR
80075(a)
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Health Related Services. (a) The licensee shall ensure that each client receives necessary first aid and other needed medical or dental services, including arrangement for and/or provision of transportation to the nearest available services. This requirement was not being met as evidenced by:
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Licensee states that in-service training will be conducted to ensure residents receive medical attention in a timely manner. A plan shall be submitted to CCL by POC date.
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Based on Interviews and record review, LPA found that R1 was complaining of pain and stated it was due to a possible UTI on 11/11/22. R1 did not see their first appointment until 11/14/22, with actual treatment occuring on 11/15/22. R1 needed to be taken to the hospital immediately. This poses a potential health and safety and 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: 11/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 4