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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 336407087
Report Date: 03/21/2023
Date Signed: 03/21/2023 10:38:57 AM

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
RIVERSIDE, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/08/2021 and conducted by Evaluator Javina George
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20211208114153
FACILITY NAME:COPPER CANYON SENIOR CAREFACILITY NUMBER:
336407087
ADMINISTRATOR:TELECIA COOKEFACILITY TYPE:
740
ADDRESS:37225 JEROME LANETELEPHONE:
(951) 677-1349
CITY:MURRIETASTATE: CAZIP CODE:
92562
CAPACITY:8CENSUS: 8DATE:
03/21/2023
UNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Telecia Cooke, LicenseeTIME COMPLETED:
10:40 AM
ALLEGATION(S):
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Licensee created a hostile environment.
Licensee prevented a visitor from leaving.
Licensee made unnecessary law enforcement contact.
INVESTIGATION FINDINGS:
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***The following report is an amended complaint report for the findins orignigally delivered on 12/10/2021.

Regarding the allegation of Licensee created a hostile environment.

LPA conducted interviews and reviewed documentation. The evidence collected revealed that on December 8, 2022, The Riverside County Long-term Care Ombudsman (LTCO) representative attempted a visit to the facility. According to interviews conducted the administrator Telecia Cooke made a request for the representative to step outside, so that the caregiver on duty could complete the required Covid screening protocol. A video collected shows the Administrator already on the phone speaking with Law Enforcement (LE). Administrator can be heard stating to LE that the LTCO representative was being non-cooperative. Administrator continued to state to LE that the LTCO representative did not identify self prior to entering and would not comply with request to have their temperature checked. LPA observed the LTCO representative with a badge hanging from the neck that is clearly visible. *** Continued on 9099c.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javina GeorgeTELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:

DATE: 03/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2023
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 7
Control Number 18-AS-20211208114153
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: COPPER CANYON SENIOR CARE
FACILITY NUMBER: 336407087
VISIT DATE: 03/21/2023
NARRATIVE
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In addition, the administrator made inferences that the LTCO representative “could have been under the influence”. While the administrator was on the phone with LE, the LTCO representative received a call from the LTCO supervisor.
The administrator hung up the phone with LE and directed her attention to the LTCO supervisor, stating that the representative would not exit the home and comply with request to be screened.
After several back and forth between the administrator and the LTCO supervisor, no clear directions were provided. As the representative is receiving final instructions by the LTCO supervisor, the administrator can be heard stating over and over, for the representative to “step outside the home”. The representative did as instructed, by the administrator and step outside the home, confirming that LE was on their way to the facility and that she would wait outside. The representative exits and leaves the home and tried to sit in their vehicle that is parked in front of the facility. The administrator made the decision to leave the home and follow the LTCO representative to the parked vehicle. LPA can hear the administrator repeatedly, asking the LTCO representative for the supervisor’s number and approaches the vehicle. The administrator places herself between the open door of the vehicle, preventing the LTCO representative from closing the door. LPA can observe that the representative makes several attempts to close the door, but is unable to do so, because of the administrator standing between the door. Based on observation the allegation of the licensee created a hostile environment, the allegation is SUBSTANTIATED.
Regarding the allegation of Licensee prevented a visitor from leaving.
On December 8, 2022, The Riverside County Long-term Care Ombudsman (LTCO) representative attempted a visit to the facility. According to interviews conducted the administrator Telecia Cooke made a request for the representative to step outside, so that the caregiver on duty could complete the required Covid screening protocol. A video collected shows the Administrator the representative is receiving final instructions by the LTCO supervisor, the administrator can be heard stating over and over, for the representative to “step outside the home”. The representative did as instructed, by the administrator and step outside the home, The representative exits and leaves the home and tried to sit in her vehicle that is parked in front of the facility.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javina GeorgeTELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:

DATE: 03/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 18-AS-20211208114153
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: COPPER CANYON SENIOR CARE
FACILITY NUMBER: 336407087
VISIT DATE: 03/21/2023
NARRATIVE
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The administrator made the decision to leave the home and follow the LTCO representative to the parked vehicle. LPA can hear the administrator repeatedly, asking the LTCO representative for the supervisor’s number and approaches the vehicle. The administrator places herself between the open door of the vehicle, preventing the LTCO representative from closing the door. LPA can observe that the representative makes several attempts to close the door, but is unable to do so, because of the administrator standing between the door. After several attempts the representative is finally able to close the door and the incident ends. Based on observation the allegation of the licensee created a hostile environment, the allegation is SUBSTANTIATED.

Regarding the allegation of Licensee made unnecessary law enforcement contact.
On December 8, 2022, The Riverside County Long-term Care Ombudsman (LTCO) representative attempted a visit to the facility. According to interviews conducted the administrator Telecia Cooke made a request for the representative to step outside, so that the caregiver on duty could complete the required Covid screening protocol. A video collected shows the Administrator already on the phone speaking with Law Enforcement (LE). Administrator can be heard stating to LE that the LTCO representative was being non-cooperative. Administrator continued to state to LE that the LTCO representative did not identify self prior to entering and would not comply with request to have her temperature checked. LPA observed the LTCO representative with a badge hanging from the neck that is clearly visible. The video also shows the LTCO showing and making the statement of “here is my credential”. Based on observation the allegation of Licensee made unnecessary law enforcement contact is SUBSTANTIATED. A finding that the complaint is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met.

An exit interview was conducted, and a copy of this report, 9099c, 9099d, and appeal rights were provided to Licensee Telecia Cooke.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javina GeorgeTELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:

DATE: 03/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 7
Control Number 18-AS-20211208114153
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: COPPER CANYON SENIOR CARE
FACILITY NUMBER: 336407087
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/21/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/04/2023
Section Cited
CCR
87468.1(a)(11)
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87468.1 Personal Rights of Residents in All Facilities.
(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (11) 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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The licensee agrees to provide a statement of staff expectations with the Ombudsman.
Proof of the POC is due by 5pm on the due date indicated.
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This requirement is not met as evidenced by: one out of one time the licensee did not permit the LTCO to enter the facility. This poses a potential personal rights risk to persons in care.
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Type B
04/04/2023
Section Cited
CCR
87405(d)
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87405 Administrator - Qualifications and Duties
(d) The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7). If the licensee is also the administrator, all requirements for an administrator shall apply. (5) Good character and a continuing reputation of personal integrity.
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The Licensee agrees to have a staff training on the Ombudsman and their rights to visit the facility.. Proof of the POC is due by 5pm on the due date indicated.
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 This requirement is not met as evidenced by: the licensee creating a hostile environment at least one time. This poses a potential personal rights risk to person’s 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.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javina GeorgeTELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:

DATE: 03/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 7
Control Number 18-AS-20211208114153
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: COPPER CANYON SENIOR CARE
FACILITY NUMBER: 336407087
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/21/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/04/2023
Section Cited
CCR
87504(h)(8)
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87405 Administrator - Qualifications and Duties (h) The administrator shall have the responsibility to: (8) Have the personal characteristics, physical energy and competence to provide care and supervision and, where applicable, to work effectively with social agencies. This requirement is not met as evidenced by: on at least one occasion the Licensee made unnecessary law enforcement contact. This poses a potential personal rights risk to person’s in care.
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The Licensee agrees to provide her statement on why it was deemed necessary to contact law environment.

Proof of the POC is due by 5pm on the due date indicated.
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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: Javina GeorgeTELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:

DATE: 03/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2023
LIC9099 (FAS) - (06/04)
Page: 7 of 7
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
12/08/2021 and conducted by Evaluator Javina George
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20211208114153

FACILITY NAME:COPPER CANYON SENIOR CAREFACILITY NUMBER:
336407087
ADMINISTRATOR:TELECIA COOKEFACILITY TYPE:
740
ADDRESS:37225 JEROME LANETELEPHONE:
(951) 677-1349
CITY:MURRIETASTATE: CAZIP CODE:
92562
CAPACITY:8CENSUS: 8DATE:
03/21/2023
UNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Telecia Cooke, LicenseeTIME COMPLETED:
10:40 AM
ALLEGATION(S):
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Licensee willfully created an act of isolation by denying access to the residents/facility from an authorized representative.
INVESTIGATION FINDINGS:
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 Licensing Program Analyst (LPA) Javina George made an unannounced visit to the facility to investigate and deliver findings for the allegations listed above. LPA met with Administrator Telecia Cooke and explained the purpose of the visit and elements of the allegations. The investigation consisted of observation, interviews, and record review.

On December 8, 2022, The Riverside County Long-term Care Ombudsman (LTCO) representative attempted a visit to the facility. According to interviews conducted the Licensee Telecia Cooke made a request for the representative to step outside, so that the caregiver on duty could complete the required Covid screening protocol. A video collected shows the Administrator already on the phone speaking with Law Enforcement (LE). The Administrator can be heard stating to LE that the LTCO representative was being non-cooperative. Administrator continued to state to LE that the LTCO representative did not identify self prior to entering and would not comply with request to have their temperature checked. LE to respond to the facility and conducted a check and there were no any health and safety converns observed. Due to the situation escalating from the back and forth exchange between the Licensee and LTCO, the allegation of is Licensee willfully created an act of isolation by denying access to the residents/facility from an authorized representative is UNSUBSTANTIATED.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javina GeorgeTELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:

DATE: 03/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 5 of 7
Control Number 18-AS-20211208114153
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: COPPER CANYON SENIOR CARE
FACILITY NUMBER: 336407087
VISIT DATE: 03/21/2023
NARRATIVE
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 A finding that the complaint is 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, therefore the allegation is unsubstantiated at this time.

An exit interview was conducted, and a copy of this report was provided to Licensee Telecia Cooke.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javina GeorgeTELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:

DATE: 03/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2023
LIC9099 (FAS) - (06/04)
Page: 6 of 7