336408502-6-9-2022-56-AS-NBRN-CMBUHX-20221221143636

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 336408502
Report Date: 06/09/2022
Date Signed: 06/09/2022 11:42:51 AM

Unfounded

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
03/08/2022 and conducted by Evaluator Amy Goldenberg

PUBLIC

COMPLAINT CONTROL NUMBER: 56-AS-20220308132028

FACILITY NAME:	CASA MIA		FACILITY NUMBER:	336408502
ADMINISTRATOR:	LILIBETH SAMSON		FACILITY TYPE:	740
ADDRESS:	10650 54TH STREET		TELEPHONE:	(951) 685-9000
CITY:	MIRA LOMA	STATE: CA	ZIP CODE:	91752
CAPACITY:	20	CENSUS: 15	DATE:	06/09/2022
		UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Lilibeth Sampson, Administrator		TIME COMPLETED:	12:00 PM

ALLEGATION(S):

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Staff not serving nutritional meals to meet the resident’s medical needs
Facility heating system is in disrepair

INVESTIGATION FINDINGS:

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This unannounced visit conducted by Amy Goldenberg, Licensing Program Analyst (LPA), is being conducted to conclude this agency’s investigation into the complaint allegations mentioned above.

During the course of this investigation LPA reviewed R1s medication and diet orders, reviewed menus, assessed food supply, interviewed three (3) staff and eight (8) of fifteen (15) residents. LPA tested resident pull alarm system and heaters. Investigation revealed the following:

It is alleged that R1 was not serving nutritional meals to meet the residents needs. LPA review of diet orders revealed that R1 had a diet order for a low carbohydrate diet. LPA review of menu and food storage indicate that a low carbohydrate diet can be provided. Interview with R1 revealed their satisfaction with the food items being served.

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Amy Goldenberg	TELEPHONE: (951) 201-3990
LICENSING EVALUATOR SIGNATURE:	DATE: 06/09/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2022

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 56-AS-20220308132028

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: CASA MIA	FACILITY NUMBER: 336408502
	VISIT DATE: 06/09/2022

NARRATIVE

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Eight (8) of eight (8) residents interviewed described the food being served as nutritious and that their needs are being met. Interviews with staff providing food service revealed their knowledge of R1's nutritional needs as related to their medical status and diet order and are able to inform LPA on how those needs are being met through appropriate meal substitutes. Review of the food storage and menus revealed that the facility has the availability of food options to meet the needs of R1s diet order.

It is alleged that the facility heating system is in disrepair. LPA toured 10 bedrooms to assess the heaters efficacy. LPA found in ten (10) of ten (10) bedrooms that the heater was functioning. Seven (7) of eight (8) residents interviewed state that their heater works to their satisfaction. One (1) of eight (8) interviewed was unable to provide a response in regard to the heater. The facility thermostats are maintained at a temperature of 73 degrees F.

Based on review of the information we have found the complaint allegations are unfounded, meaning that the allegation was false, could not have happened and is without a reasonable basis. We have therefore dismissed the complaint. A copy of this report is being reviewed with, and furnished to the facility representative.

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Amy Goldenberg	TELEPHONE: (951) 201-3990
LICENSING EVALUATOR SIGNATURE:	DATE: 06/09/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 4

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
03/08/2022 and conducted by Evaluator Amy Goldenberg

PUBLIC

COMPLAINT CONTROL NUMBER: 56-AS-20220308132028

FACILITY NAME:	CASA MIA		FACILITY NUMBER:	336408502
ADMINISTRATOR:	LILIBETH SAMSON		FACILITY TYPE:	740
ADDRESS:	10650 54TH STREET		TELEPHONE:	(951) 685-9000
CITY:	MIRA LOMA	STATE: CA	ZIP CODE:	91752
CAPACITY:	20	CENSUS: 15	DATE:	06/09/2022
		UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Lilibeth Samson, Administrator		TIME COMPLETED:	12:00 PM

ALLEGATION(S):

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Administrator threaten to evict a resident
Staff did not respond to resident's call pendent

INVESTIGATION FINDINGS:

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13

This unannounced visit conducted by Amy Goldenberg, Licensing Program Analyst (LPA), is being conducted to conclude this agency’s investigation into the complaint allegation mentioned above.

During the course of this investigation LPA reviewed R1s medication and diet orders, reviewed menus, assessed food supply, interviewed three (3) staff and eight (8) of fifteen (15) residents. LPA tested resident pull alarm system and heaters. Investigation revealed the following:

It is alleged that the facility administrator threatened to evict R1. It is alleged that R1 spoke with their representatives stating that the administrator told them, "You can just leave then". R1 refused to discuss the allegation. Staff interviewed deny the allegation occurred. Six (6) of eight (8) residents interviewed report that they have never been threatend to be evicted or told to move. Two (2) of Eight (8) residents interviewed did not provide a response.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Amy Goldenberg	TELEPHONE: (951) 201-3990
LICENSING EVALUATOR SIGNATURE:	DATE: 06/09/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 56-AS-20220308132028

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: CASA MIA	FACILITY NUMBER: 336408502
	VISIT DATE: 06/09/2022

NARRATIVE

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It is alleged that staff did not respond to R1 call bell. LPA tested the call system and verified that the call system is working in the bedroom of R1. LPA notes that the alarm system rings loudly and is heard through out the facility. Interview of residents revealed that one (R1) of eight (8) interviewed responds that staff did not respond to their call bell. Staff interviewed deny the allegation. There is no evidence available to confirm or refute that staff did not respond to R1's call for assistance.

We have found the complaint allegation is unsubstantiated, although the allegation may have happened or is valid: there is not a preponderance of the evidence to prove that the alleged violation occurred. A copy of this report is being reviewed with and furnished to the facility representative.

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Amy Goldenberg	TELEPHONE: (951) 201-3990
LICENSING EVALUATOR SIGNATURE:	DATE: 06/09/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2022

LIC9099 (FAS) - (06/04)

Page: 4 of 4