<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331881368
Report Date: 08/03/2023
Date Signed: 08/03/2023 04:50:55 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE AC/SC, 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
07/28/2023 and conducted by Evaluator Sara Martinez
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20230728091503
FACILITY NAME:LEGACY OF HEMET 1, THEFACILITY NUMBER:
331881368
ADMINISTRATOR:KELLOGG, MICHELLEFACILITY TYPE:
740
ADDRESS:320 S SAN JACINTO STTELEPHONE:
(951) 765-1840
CITY:HEMETSTATE: CAZIP CODE:
92543
CAPACITY:16CENSUS: 13DATE:
08/03/2023
UNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Kailene Martinez - SupervisorTIME COMPLETED:
05:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not issue a refund to resident's authorized representative
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Sara Martinez arrived unannounced to the facility to initiate an investigation into the allegation listed above. LPA met with Facility Manager Kailene Martinez and explained the purpose of the visit. LPA conducted interviews with the staff and gathered and reviewed pertinent documentation in relation to this investigation.

It was alleged that a refund of $2,404.84 for Resident One (R1) had not been issued and received within 15 days of moving R1's personal belongings out of the facility per the facility's admission agreement for R1.

LPA's interviews with staff, Reporting Party (RP), and record review revealed that due to miscommunication regarding R1's living trust and the entity the refund needed to be issued to, this complaint was submitted two days after the full refund was issued to the RP. Thus this allegation was Unsubstantiated.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Sara MartinezTELEPHONE: (951) 248-0314
LICENSING EVALUATOR SIGNATURE:

DATE: 08/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2023
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-20230728091503
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: LEGACY OF HEMET 1, THE
FACILITY NUMBER: 331881368
VISIT DATE: 08/03/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
A finding of UNSUBSTANTIATED means that 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.

An exit interview was conducted where a copy of this report was discussed with and provided to Supervisor Kailene Martinez
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Sara MartinezTELEPHONE: (951) 248-0314
LICENSING EVALUATOR SIGNATURE:

DATE: 08/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2