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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 336406665
Report Date: 06/17/2020
Date Signed: 09/28/2021 01:17:22 PM



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
12/13/2019 and conducted by Evaluator Yolanda Bejarano
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20191213161336
FACILITY NAME:BOUNDLESS CARE FOR THE ELDERLYFACILITY NUMBER:
336406665
ADMINISTRATOR:SANDRA CHOCOBARFACILITY TYPE:
740
ADDRESS:26086 SHADY OAK COURTTELEPHONE:
(951) 461-1035
CITY:MURRIETASTATE: CAZIP CODE:
92563
CAPACITY:4CENSUS: 4DATE:
06/17/2020
ANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Sandra Chocobar TIME COMPLETED:
11:10 AM
ALLEGATION(S):
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Facility failed to acknowledge the residents change of condition leading the resident reoccurring unexplained injuries.

Facility staff required visitors to give advance notice before visiting resident

Facility staff did not use residents wheelchair in a safe manner
INVESTIGATION FINDINGS:
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Licensing Program Analyst Yolanda Bejarano conducted an unannounced visit to deliver findings. LPA explained the purpose of the visit to Sandra Chocobar.

Allegation "Facility failed to acknowledge the residents change of condition leading the resident reoccurring unexplained injuries". LPA was provided documentation for R1 that revealed a change of condition had occurred on 10/4/2019. Facility provided the responsible party an increase of fees but failed to document change of condition. Administrator provided a time line, photos, text, documentation of injuries that had occurred. However, no change of condition was in file. Based on the documentation gathered the allegation is deemed to be SUBSTANTIATED. A finding that the complaint SUBSTANTIATED means that the allegation(s) is valid because the preponderance of the evidence standard has been met.

Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Crystal ColvinTELEPHONE: (951) 2176360
LICENSING EVALUATOR SIGNATURE:

DATE: 06/17/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2020
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 4
Control Number 18-AS-20191213161336
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: BOUNDLESS CARE FOR THE ELDERLY
FACILITY NUMBER: 336406665
VISIT DATE: 06/17/2020
NARRATIVE
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Allegation:"Facility staff required visitors to give advance notice before visiting residents". LPA interviewed administrator and stated families and outside agencies are to call prior to visiting due to housekeeping hours and to prevent families from visiting all at the same time. Based on the interview, LPA found administrator limited visitations, this is a violation of residents personal rights. Families should be able to visit during reasonable hours without prior notice. The allegation is deemed to be SUBSTANTIATED. A finding that the complaint is SUBSTANTIATED means that the allegation(s) is valid because the preponderance of the evidence standard has been met.

Allegation: Facility staff did not use residents wheelchair in a safe manner
LPA Yolanda Bejarano visited the facility on 12/17/2019, resident #1 was no longer living at the facility therefore was unable to interview. Administrator admitted the legs on the wheelchair had been removed to prevent injury to resident legs. R1 was able to transfer to and from the wheelchair with assistance. File review for R1 was conducted but there was documentation indicating legs could be removed on wheelchair. Based on the information gathered the allegation is deemed to be SUBSTANTIATED. A finding that the complaint is SUBSTANTIATED means that the allegation(s) is valid because the preponderance of the evidence standard has been met.

Exit interview conducted and copy of report provided.


**** LIC9099 & LIC9099C were signed by LPA Colvin and sent via email to Licensee Sandra Chocobar. Signatures needed for amended report to change status of report from confidential to public. Signature of Licensee on file.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Crystal ColvinTELEPHONE: (951) 2176360
LICENSING EVALUATOR SIGNATURE:

DATE: 06/12/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/27/2020
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 18-AS-20191213161336
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: BOUNDLESS CARE FOR THE ELDERLY
FACILITY NUMBER: 336406665
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/17/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/30/2020
Section Cited
CCR
87466
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OBSERVATION OF THE RESIDENT
The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. When changes such as unusual weight gains or losses or deterioration of mental ability or a physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any.
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Administrator is to ensure at all times that residents are regularly observed for changes and the appropriate assistance is provided when such observation reveals unmet needs.

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This requirement is no met as evidence by:

Administrator did not observe R1's change of condition and ensure the needs and assistance was met that lead R1 to have reoccurring unexplained injuries.
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Submit statement indicating how this will take place and training will be provided.
Type B
06/30/2020
Section Cited
ILS
87468.1(a)(11)
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PERSONAL RIGHTS
Residents in all residential care facilities for the elderly shall have all of the following personal rights:
To have their visitors, including ombudspersons and advocacy representatives, permitted to visit privately during reasonable hours and without prior notice, provided that the rights of other residents are not infringed upon.
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Administrator is to understand the regulation that visitors are permitted to have vistors without prior notice.
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This requirement is no met as evidence by:

Facility requires vistors and any agency to give advance notice before visiting the facility or any of the residents
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Statement of ccorections is to be submitted to CCL by the due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Yolanda BejaranoTELEPHONE: (951) 2176360
LICENSING EVALUATOR SIGNATURE:

DATE: 06/23/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2020
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 18-AS-20191213161336
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: BOUNDLESS CARE FOR THE ELDERLY
FACILITY NUMBER: 336406665
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/17/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/30/2020
Section Cited
CCR
87608(a)(3)
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POSTURAL SUPPORTS
Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions.
A written order from a physician indicating the need for the postural support shall be maintained in the resident’s record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order.
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Administrator is to ensure at all times that there is a written order from a physician prior to making an changes to the use of Postural Supports.
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This requirement is no met as evidence by:

Facility did not use the wheel chair in a safe manner and removed the foot pedals without a written order from a physician which caused injuries.
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Administrator is to review and understand the regulation and submit statement and corrections to CCL by the due date.
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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.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Yolanda BejaranoTELEPHONE: (951) 2176360
LICENSING EVALUATOR SIGNATURE:

DATE: 06/17/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2020
LIC9099 (FAS) - (06/04)
Page: 4 of 4