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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 335530063
Report Date: 04/11/2024
Date Signed: 04/11/2024 03:09:39 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
, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/09/2024 and conducted by Evaluator Melody Brown
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20240409145944
FACILITY NAME:SIERRA PINES GUEST HOMEFACILITY NUMBER:
335530063
ADMINISTRATOR:HAMED, HANANFACILITY TYPE:
740
ADDRESS:5051 LA SIERRA AVETELEPHONE:
(786) 219-6008
CITY:RIVERSIDESTATE: CAZIP CODE:
92505
CAPACITY:25CENSUS: 24DATE:
04/11/2024
UNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Carmencita FajardoTIME COMPLETED:
03:20 PM
ALLEGATION(S):
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Facility staff is serving as resident's power of attorney.
INVESTIGATION FINDINGS:
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On 04/11/2024 at 01:45 PM, Licensing Program Analyst (LPA) Melody Brown conducted an unannounced visit to the facility to commence a complaint investigation. LPA Brown was greeted and granted entrance by a staff member and LPA Brown met with staff Carmencita Fajardo . LPA Brown identified herself and discussed the purpose of the visit and the elements of the allegation with staff Carmencita Fajardo.

The investigation was conducted by LPA Brown. The investigation consisted of file review and interviews with relevant parties. The allegation indicated that Facility staff is serving as resident's power of attorney. LPA Brown was able to obtain evidence to corroborate the allegation. Interview with Resident #1 (R1) indicated that R1 does not have an idea that R1 designated Staff #1 (S1) as R1's Power of Attorney (POA). R1 reported to LPA Brown that R1 did not sign a POA document indicating S1 as R1's POA.

***Continuation on LIC9099C***
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 04/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2024
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 56-AS-20240409145944
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
, CA 92507
FACILITY NAME: SIERRA PINES GUEST HOME
FACILITY NUMBER: 335530063
VISIT DATE: 04/11/2024
NARRATIVE
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LPA Brown interviewed S1 and S1 confirmed to LPA Brown that S1 is R1's POA. S1 revealed to LPA Brown that S1's unaware that a facility staff's not allowed as POA for a resident. LPA Brown reviewed R1's facility documents and LPA Brown observed R1's signed and notarized durable Power of Attorney assigning S1 as R1's POA on 10/18/2022.

Based on LPA Brown’s observations and interviews and review of records, the preponderance of evidence standard has been met, therefore the allegation Facility staff is serving as resident's power of attorney is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6, Health and Safety Code) is being cited on the attached LIC9099D.

An exit interview was conducted where this report, LIC9099, LIC9099D, and Appeal Rights were discussed and provided to staff Carmencita Fajardo.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 04/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 56-AS-20240409145944
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
, CA 92507

FACILITY NAME: SIERRA PINES GUEST HOME
FACILITY NUMBER: 335530063
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/11/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/12/2024
Section Cited
HSC
1569.269(a)(29)(C)
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1569.269 Enumerated rights; severability (a) Residents of residential care facilities for the elderly shall have all of the following rights: (29)To manage their financial affairs. A licensee shall not require residents to deposit their personal funds with the licensee. Except as provided in approved continuing care agreements, a licensee, or a spouse, domestic partner, relative, or employee of a licensee, shall not do any of the following: (C) Serve as an agent for a resident under any general or special power of attorney. This requirement is not met as evidenced by:
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Licensee stated to cease S1 as the POA for R1 and start the Public Guardian Application for R1 and submit proof to LPA Brown on Plan of Correction (POC) due date.
Licensee stated to submit Signed Statement of Understanding on HSC 1569.269(a)(29)(C) and a statement that will reflect that S1 will no longer be R1's POA to LPA Brown on Plan of Correction (POC) due date.
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Based on observation, interview and record review, the Licensee did not comply with the section cited above by alowing Staff #1 (S1) as Resident #1 (R1) Power of Attorney as evidenced of Signed and Notarized Power of Attorney with date 10/18/2022 which pose an immediate health, safety and personal rights risks to resident 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: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 04/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3