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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 336409886
Report Date: 04/25/2022
Date Signed: 04/25/2022 03:45:09 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
04/22/2022 and conducted by Evaluator Jennifer Semin
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20220422103235
FACILITY NAME:NEW LIFE RESIDENCEFACILITY NUMBER:
336409886
ADMINISTRATOR:ANA MARIA SANTALLAFACILITY TYPE:
735
ADDRESS:7384 HIGH KNOLL CIRCLETELEPHONE:
(951) 737-9323
CITY:CORONASTATE: CAZIP CODE:
92881
CAPACITY:6CENSUS: 3DATE:
04/25/2022
UNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Ana Maria SantallaTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Licensee failed to comply with incident reporting requirements.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Jennifer Semin conducted an unannounced visit to initiate and deliver the findings for the above allegation. LPA met with Licensee/Administrator Ana Maria Santalla

The investigation consisted of interviews and review of records. The allegation, Licensee failed to comply with incident reporting requirements. Ms. Santalla stated the Incident Report was sent to Inland Regional Center (IRC) using IRC’s direct email link on 4/21/2022, but did not get conformation that it went through. Ms. Santalla stated the incident report was not sent to Community Care Licensing (CCL). LPA also did not see this incident report in the CCL Adult and Senior Care Duty Log.
Based upon interviews conducted and information gathered, the preponderance of the evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED, California Code of Regulations Title 22 is being cited on the attached LIC 9099D.

An exit interview was conducted where this report, LIO9099D and appeal rights were discussed and provided to Ms. Santalla.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Jennifer Semin
LICENSING EVALUATOR SIGNATURE:

DATE: 04/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2022
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 2
Control Number 56-AS-20220422103235
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: NEW LIFE RESIDENCE
FACILITY NUMBER: 336409886
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/25/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/02/2022
Section Cited
CCR
80061(b)(1)(E)
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Reporting Requirements Upon the occurrence, during the operation of the facility...a report shall be made to the licensing agency within the agency's next working day during its normal business hours. In addition, a written report containing the information...shall be submitted to the licensing agency within
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Licensee shall read the regulation in its entirety, submit a statement of undertanding, train staff on this regulation and submit a training log by the POC due date of 5/2/2022.
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seven days following the occurrence of such event. Any unusual incident or client absence which threatens the physical or emotional health or safety of any client. This requirement was not met as evidenced by, Administrator stated Incident Report was not sent to CCL. This poses a potential risk to clients 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: Jennifer Semin
LICENSING EVALUATOR SIGNATURE:

DATE: 04/25/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2