331881421-5-13-2025-18-AS-JDHS-DGQTHC-20250516144429

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 331881421
Report Date: 05/13/2025
Date Signed: 05/13/2025 09:51:53 AM

Unfounded

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
03/10/2025 and conducted by Evaluator Armando Perez

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20250310124409

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: 11	DATE:	05/13/2025
		UNANNOUNCED	TIME BEGAN:	09:20 AM
MET WITH:	Administrator Ma Satchel Lecita		TIME COMPLETED:	09:55 AM

ALLEGATION(S):

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Staff did not notify responsible representative regarding incident involving resident.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA), Armando Perez, conducted an unannounced visit to deliver findings for a complaint investigation regarding the above allegation. LPA Perez met with Administrator, Ma Satchel Lecita, where the LPA explained the purpose of the visit and the elements of the allegation. The investigation consisted of interviews with staff and witnesses and file reviews.

On March 10, 2025, Community Care Licensing received a complaint alleging that staff did not notify responsible representative regarding an incident involving Resident. It was alleged that on March 8, 2025, Resident (R1) was transferred to the hospital for medical evaluation and assistance. It further alleged that staff did not report the hospitalization with R1’s designated responsible representative. Information obtained from Administrator, Ma Satchel Lecita stated that R1 did not provide a responsible party during the intake process. Administrator also denied that there was written or verbal instruction to revise documentation designating a responsible party or emergency contact.
Continued on 9099-C.

Unfounded

Estimated Days of Completion:

SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Armando Perez
LICENSING EVALUATOR SIGNATURE:	DATE: 05/13/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2025

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-20250310124409

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: SMITH ROAD ASSISTED LIVING	FACILITY NUMBER: 331881421
	VISIT DATE: 05/13/2025

NARRATIVE

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According to the Administrator, R1 consistently refused to identify a responsible party or share contact information for any additional witness. R1 indicated and documented that they were their own emergency contact and specifically directed staff not to reach out to additional witnesses. Administrator stated they advised R1 to add a responsible party, but R1 consistently refused indicating that they have the ability to make their own decisions. Furthermore, Administrator stated that they had multiple conversations with Additional Witness (AW1) to confirm contact information to report any information pertaining to R1. However, AW1 repeatedly refused to provide the requested information on documents. It was advised that on March 9, 2025, AW1 did visit the facility and was advise that R1 was in the hospital. The notification did abide by the time frame set in place by Title 22 Regulations regarding reporting requirements. Information obtained from an interview with AW1 revealed they had spoken by phone with the Administrator and Staff 2 (S2) around the time R1 was admitted to the facility. AW1 believed that facility staff having the knowledge of their phone contact information was sufficient to assume responsibility for R1. However, AW1 stated they never verbally confirmed nor completed any paperwork designating themselves as R1’s emergency contact. AW1 did corroborate that on March 9, 2025, during a visit to the facility, they were advised of R1’s hospitalization by facility staff. Information from additional witnesses also stated they were not the current or listed responsible party for R1. A review of admission records revealed that the admissions agreement between R1 and the facility did not designate a responsible party. During the intake process, R1 explicitly wrote “none” in the section for a responsible party signature on multiple documents. Additionally, the Emergency Contact Form and Resident Roster did not list a responsible party for R1. R1 was unable to be interviewed regarding the allegations due to the death of R1.

Based on interviews, research, and record review, the allegation that staff did not notify responsible representative regarding an incident involving resident in care is unfounded. AW1 was not documented as a responsible party for R1 for the facility to be required to notify of any incident regarding R1. Also, on March 9, 2025, facility staff did advise AW1 that R1 was in the hospital. A finding that the allegation is unfounded meaning that the allegation was false, could not have happened, and/or is without a reasonable basis. This allegation has been investigated and is dismissed

An exit interview was conducted where a copy of this report was provided to facility representative.

SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Armando Perez
LICENSING EVALUATOR SIGNATURE:	DATE: 05/13/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2025

LIC9099 (FAS) - (06/04)

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