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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331881324
Report Date: 12/15/2022
Date Signed: 12/15/2022 12:25:47 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
12/12/2022 and conducted by Evaluator Tricia Danielson
COMPLAINT CONTROL NUMBER: 18-AS-20221212160952
FACILITY NAME:EXECUTIVE RESIDENTIAL CARE & RECOVERY LLCFACILITY NUMBER:
331881324
ADMINISTRATOR:TAYLOR, SUSAN JDFACILITY TYPE:
772
ADDRESS:70806 HALPER LAKETELEPHONE:
(562) 755-9734
CITY:RANCHO MIRAGESTATE: CAZIP CODE:
92270
CAPACITY:6CENSUS: 0DATE:
12/15/2022
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Andrew Whynaught, Program DirectorTIME COMPLETED:
12:30 PM
ALLEGATION(S):
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Facility did not notify licensing of facility alterations
INVESTIGATION FINDINGS:
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Licensing Program Analyst(LPA) Tricia Danielson arrived unannounced to the facility to initiate an investigation into the allegation listed above. LPA met with Program Manager Andrew Whynaught and explained the purpose of today's visit. There were no residents present in the facility during today's visit.
During today's visit, LPA toured the facility and interviewed one(1) staff. Regarding the allegation "Facility did not notify licensing of facility alterations", it was alleged that the facility did not notify Community Care Licensing(CCL) of property damage suffered from a water heater leak and the damaged areas required repair. CCL records reviewed revealed no notification was provided as required and a tour of the facility revealed several rooms taped of with plastic during the construction. LPA also observed a worker preparing a shower area for repair with hot tar. The rooms taped off were observed to be very dusty from the sanding of newly repaired drywall and/or baseboards. Interview with Program Manager Whynaught indicated baseboards and tile damaged by the water leak were being repaired. Based on LPA’s observations, interview which was conducted and records reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), is being cited on the attached LIC 9099 D. A copy of list report and appeal rights was provided.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Deborah Mullen
LICENSING EVALUATOR NAME: Tricia Danielson
LICENSING EVALUATOR SIGNATURE:

DATE: 12/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2022
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 3
Control Number 18-AS-20221212160952
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: EXECUTIVE RESIDENTIAL CARE & RECOVERY LLC
FACILITY NUMBER: 331881324
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/15/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/29/2022
Section Cited
CCR
81086(a)
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Alterations to existing buildings or new facilities- (a)Prior to construction or alterations, all licensees shall notify the licensing agency of the proposed change. This requirement was not met as evidenced by: The licensee did not provide notification to CCL regarding a water heater leak which damaged various areas to the property.
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Facility stated a written statement of understanding of the regulation cited and reporting requirements training for all facility staff will be completed by POC due date of 12/29/2022. Proof of POC will be submitted to CCL by POC due date of 12/29/2022.
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LPA observed active construction to repair damage from the water leak and interview with Program Manager revealed notification was made to Dept. of Health Care Services but not CCL and that the construction was to repair damage due to the water leak. This poses a potential health, 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: Tricia Danielson
LICENSING EVALUATOR SIGNATURE:

DATE: 12/15/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3