331881421-3-7-2023-18-AS-JESL-CQCVMC-20230328163316

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 331881421
Report Date: 03/07/2023
Date Signed: 03/07/2023 02:40:52 PM

Unsubstantiated

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
02/27/2023 and conducted by Evaluator Tricia Danielson

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20230227095711

FACILITY NAME:	SMITH ROAD ASSISTED LIVING		FACILITY NUMBER:	331881421
ADMINISTRATOR:	LECITA, MA SATCHEL		FACILITY TYPE:	740
ADDRESS:	753 SMITH ROAD		TELEPHONE:	(951) 927-8178
CITY:	HEMET	STATE: CA	ZIP CODE:	92544
CAPACITY:	12	CENSUS: 8	DATE:	03/07/2023
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Ma Satchel Lecita, Administrator		TIME COMPLETED:	02:45 PM

ALLEGATION(S):

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Unlicensed care being provided

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPAs) Tricia Danielson and Jesse Gardner arrived unannounced to initiate an investigation into the allegation listed above. LPAs met with Administrator Ma Satchel Lecita and explained the purpose of the visit. This home currently has eight (8) residents residing here.

LPAs interviewed eight (8) residents. Five (5) of eight (8) residents do not require care and supervision and are independent on all activities of daily living (ADLs). Three (3) of eight (8) (R2, R5, R8) are receiving hospice services from outside agencies for assistance with ADLs. LPAs verified hospice services with the agencies for all three (3) residents. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated.
An exit interview was conducted and a copy of this report was provided along with LIC811- Confidential Names list.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Deborah Mullen	TELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Tricia Danielson	TELEPHONE: (951) 565-7254
LICENSING EVALUATOR SIGNATURE:	DATE: 03/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2023

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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