331881316-5-30-2023-18-AS-JESL-CTA6PY-20230629205955

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 331881316
Report Date: 05/30/2023
Date Signed: 05/30/2023 11:27:37 AM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 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
05/22/2023 and conducted by Evaluator Jesse Gardner

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20230522152153

FACILITY NAME:	DESERT CYPRESS ELDERCARE		FACILITY NUMBER:	331881316
ADMINISTRATOR:	CAYABYAB, ARCITA A		FACILITY TYPE:	740
ADDRESS:	68905 HERMOSILLO ROAD		TELEPHONE:	(760) 459-3214
CITY:	CATHEDRAL CITY	STATE: CA	ZIP CODE:	92234
CAPACITY:	6	CENSUS: 5	DATE:	05/30/2023
		UNANNOUNCED	TIME BEGAN:	09:17 AM
MET WITH:	Arcita Cabyabyab, Administrator		TIME COMPLETED:	11:35 AM

ALLEGATION(S):

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Staff left residents unsupervised for an extended period of time.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Jesse Gardner, conducted an unannounced visit to the facility to initiate the investigation into the allegation listed above. LPA arrived, and met with Adminsitrator Arcita Cabyabyab, explained the reason for the visit, and toured the facility. LPA interviewed staff and residents, and conducted record review.

It was alleged that on May 19, 2023, staff left Resident One (R1), and Resident Two (R2) at a local grocery store without supervision. Residents were allegedly inside the store for approximately an hour.

Continued on LIC9099C.

Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Jesse Gardner
LICENSING EVALUATOR SIGNATURE:	DATE: 05/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2023

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 18-AS-20230522152153

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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

FACILITY NAME: DESERT CYPRESS ELDERCARE	FACILITY NUMBER: 331881316
	VISIT DATE: 05/30/2023

NARRATIVE

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The Department reviewed facility records which indicate that each resident will have continuous monitoring to ensure general health, safety, and well-being. Resident records indicated that R1 cannot manage their own equipment (wheelchair) and cannot leave the facility unassisted. Record review for R2 indicated that they cannot leave the facility unassisted and they need supervision. Staff interview revealed that the residents (R1, and R2) were left inside of the store without monitoring, while staff was away.

Resident interview revealed that, indeed, the residents were left inside the store without staff supervision, and approached security when they did not have the means to contact the administrator.

The Department investigated the complaint, and through record review, and staff, and resident interview found the allegation to be Substantiated. A finding that the complaint is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met. Thus, the facility was cited per Title 22.

An exit interview was conducted where a copy of this report was provided along with copies of the LIC9099D, and Appeal Rights.

SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Jesse Gardner
LICENSING EVALUATOR SIGNATURE:	DATE: 05/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 18-AS-20230522152153

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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

FACILITY NAME: DESERT CYPRESS ELDERCARE	FACILITY NUMBER: 331881316
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/30/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 06/05/2023 Section Cited HSC 1569.312(e)	1 2 3 4 5 6 7	Basic Services Requirements:Every facility required to be licensed under this chapter shall provide at least the following basic services: (e) Monitoring the activities of the residents while they are under the supervision of the facility to ensure their general health, safety, and well-being. This requirement was not being met as evidenced by:	1 2 3 4 5 6 7	Licensee to review regulation, and provide in-service training of the cited regulation to all staff and provide proof of such to LPA by POC date.
	8 9 10 11 12 13 14	Based on staff interview, LPA found that R1, and R2 were left alone at a local grocery store without monitoring by staff. This is a potential health and safety risk to residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Joel Esquivel
LICENSING EVALUATOR NAME: Jesse Gardner
LICENSING EVALUATOR SIGNATURE:	DATE: 05/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2023

LIC9099 (FAS) - (06/04)

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