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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331881318
Report Date: 10/19/2023
Date Signed: 10/19/2023 11:40:43 AM

Unsubstantiated


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
10/12/2023 and conducted by Evaluator Stephanie Martinez
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20231012101521
FACILITY NAME:ABUNDANT GRACE SENIOR LIVINGFACILITY NUMBER:
331881318
ADMINISTRATOR:ARZU, KANISHAFACILITY TYPE:
740
ADDRESS:43307 PUTTERS LANETELEPHONE:
(562) 551-1218
CITY:HEMETSTATE: CAZIP CODE:
92544
CAPACITY:6CENSUS: 2DATE:
10/19/2023
UNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Kanisha Arzu, AdministratorTIME COMPLETED:
11:45 AM
ALLEGATION(S):
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Staff did not administer resident's medication as prescribed
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Stephanie Martinez, conducted an unannounced visit to the facility to start the investigation into the above allegation. The LPA met with Administrator, Kanisha Arzu, and informed her of the purpose for her visit.

A report was received by the Department alleging a resident in care, Resident One (R1), did not receive one of their medications which caused the resident to be hospitalized on 10/11/2023. Administrator, Kanisha, was interviewed; she reported R1 was admitted to the facility on 10/05/2023 from a skilled nursing facility (SNF). She reported R1's medications were received at admission, however, necessary equipment to administer one of the medications was not available. Text messages between the Administrator and the SNF Discharge Coordinator were received from the facility. The text messages revealed a request was made by the Administrator on 10/06/2023 to obtain the necessary equipment so R1's medication could be administered. Text messages from 10/10/2023 show the SNF Discharge Coordinator reported there was still no response provided from their intake team regarding the medication equipment. The SNF Discharge Coordinator was
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Rikesha StampsTELEPHONE: (951) -212-0616
LICENSING EVALUATOR NAME: Stephanie MartinezTELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:

DATE: 10/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2023
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-20231012101521
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: ABUNDANT GRACE SENIOR LIVING
FACILITY NUMBER: 331881318
VISIT DATE: 10/19/2023
NARRATIVE
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interviewed and reported they believed the equipment for R1's medication was not provided; however, instruction was given on how to administer the medication with alternate equipment. Per Administrator and staff, alternate equipment was not available.

An inspection of R1's medication and medication equipment could not be conducted due to the resident's medication no longer being available at the facility.

Therefore, due to insufficient information, this allegation is deemed UNSUBSTANTIATED at this time. A finding that the complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

An exit interview was conducted; this report was reviewed with Administrator Arzu and a copy was provided.
SUPERVISOR'S NAME: Rikesha StampsTELEPHONE: (951) -212-0616
LICENSING EVALUATOR NAME: Stephanie MartinezTELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:

DATE: 10/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2