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

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 336405670
Report Date: 08/26/2021
Date Signed: 08/26/2021 01:23:57 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
01/15/2020 and conducted by Evaluator Crystal Colvin
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20200115104818
FACILITY NAME:SLB INCORPORATED-MESA TOPFACILITY NUMBER:
336405670
ADMINISTRATOR:LIBERTY HALLFACILITY TYPE:
735
ADDRESS:28331 MESA TOP TRAILTELEPHONE:
(951) 485-6779
CITY:MORENO VALLEYSTATE: CAZIP CODE:
92555
CAPACITY:6CENSUS: 6DATE:
08/26/2021
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Michael Hall - AdministratorTIME COMPLETED:
12:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff neglect resulted in resident being septic
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Crystal Colvin arrived at the facility unannounced for the purpose of delivering findings for an open complaint investigation with the above allegation. LPA identified herself and met with Administrator Michael Hall and advised him of the purpose of today's visit. Below is a summary of the findings of the investigation:

Regarding allegation: "Staff neglect resulted in resident being septic": LPA Colvin reviewed Resident #1 (R1) medical records, facility records, as well as staff records. LPA Colvin found that R1 had been in and out of the hospital multiple times due to various medical concerns from September 25, 2019 to January 22, 2020. Facility Records indicate staff ensuring follow up with proper admiration of medications as prescribed at discharge. LPA Colvin was unable to find corroborating evidence that R1's diagnosis of sepsis during any of R1's hospitalizations was due to lack of adequate care or neglect on behalf of care staff.Therefore, due to records review and interviews, the allegation of "Staff neglect resulted in resident being septic" is UNSUBSTANTIATED.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Crystal Colvin
LICENSING EVALUATOR SIGNATURE:

DATE: 08/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2021
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-20200115104818
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: SLB INCORPORATED-MESA TOP
FACILITY NUMBER: 336405670
VISIT DATE: 08/26/2021
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 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 with Administrator Michael Hall and a copy of this report was provided.


****Note: An technical error was made and as a result, a deficiency page (LIC 9099D) was created in relation to this complaint. Please note that no deficiencies were cited for this complaint and that an LIC 9099D attached to this complaint is an error and invalid.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Crystal Colvin
LICENSING EVALUATOR SIGNATURE:

DATE: 09/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 18-AS-20200115104818
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: SLB INCORPORATED-MESA TOP
FACILITY NUMBER: 336405670
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/26/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/27/2021
Section Cited
CCR
80065(a)
1
2
3
4
5
6
7
Personnel Requirements: (a) Facility personnel shall be competent to provide the services necessary to meet individual client needs and shall, at all times, be employed in numbers necessary to meet such needs. This requirement was not met by:
1
2
3
4
5
6
7
Licensee agrees to audit all staff records for those who work at facility to ensure all training for residents' in care needs are up to date. Licensee may self-ceritfy to LPA Colvin once complete. Self-Certification due by Plan of Correction date of 8/27/21.
8
9
10
11
12
13
14
Based on record review, the Licensee did not comply with the above regulation with 5 staff (S1 - S5). LPA Colvin observed that 5 staff members worked (December 2019 & January 2020), but did not receive training on glucose testing until 1/24/20. No training records for S4 & S5. This was immediate health risk to R1.
8
9
10
11
12
13
14
Type A
08/27/2021
Section Cited
CCR
80078(a)
1
2
3
4
5
6
7
Responsibility for Providing Care and Supervision: (a) The licensee shall provide care and supervision as necessary to meet the client's needs. This requirement was not met as evidenced by:
1
2
3
4
5
6
7
No plan of correction required.
8
9
10
11
12
13
14
Based on record review, the Licensee did not comply with the above regulation with 1 resident (R1). Hospital records show that R1's discharge from the hospital was delayed 2 days due to hospital not being able to reach facility Administrator. This was an immedaite personal rights violation to R1.
8
9
10
11
12
13
14
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: Joel Esquivel
LICENSING EVALUATOR NAME: Crystal Colvin
LICENSING EVALUATOR SIGNATURE:

DATE: 08/26/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 3