336410270-5-18-2022-18-AS-DMUN-CMA2ZJ-20221219165021

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 336410270
Report Date: 05/18/2022
Date Signed: 05/18/2022 04:04:03 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
RIVERSIDE, CA 92507

This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/22/2022 and conducted by Evaluator Tricia Danielson

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20220322141019

FACILITY NAME:	CHRISTMAS COTTAGE		FACILITY NUMBER:	336410270
ADMINISTRATOR:	VICTORIA J. SARSON		FACILITY TYPE:	740
ADDRESS:	330 S. SAN JACINTO ST		TELEPHONE:	(951) 765-1840
CITY:	HEMET	STATE: CA	ZIP CODE:	92543
CAPACITY:	14	CENSUS: 14	DATE:	05/18/2022
		UNANNOUNCED	TIME BEGAN:	03:35 PM
MET WITH:	Katheen Hyland, Manager		TIME COMPLETED:	04:10 PM

ALLEGATION(S):

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Staff had resident's power of attorney

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Tricia Danielson arrived unannounced to conclude an investigation into the allegation listed above. LPA met with Kathleen Hyland, Manager and explained the purpose of the visit.

Regarding the allegation "Staff had resident's power of attorney", it was alleged that Staff #1 (S1) obtained the power of attorney pertaining to Resident #1 (R1). Review of R1's records revealed a signed power of attorney document which indicated power of attorney for R1 was held by S1. During LPA interview with S1, S1 acknowledged being the power of attorney for R1 due to the belief that R1 did not have any family left to assist them.

Based on LPA's observations, interviews which were conducted, and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, Chapter 8 is being cited on the attached LIC 9099D. An exit interview as conducted with Hyland and a copy of this report was provided along with Appeal Rights.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Deborah Mullen	TELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Tricia Danielson	TELEPHONE: (951) 565-7254
LICENSING EVALUATOR SIGNATURE:	DATE: 05/18/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2022

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

LIC9099 (FAS) - (06/04)

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Control Number 18-AS-20220322141019

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: CHRISTMAS COTTAGE	FACILITY NUMBER: 336410270
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/18/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 05/31/2022 Section Cited CCR 87217(d)(2)	1 2 3 4 5 6 7	Safeguards for Resident Cash, Personal Property, and Valuables- d) Except as provided in approved continuing care agreements, no licensee or employee of a facility shall:(2) accept any general or special power of attorney for any such person; This requirement was not met as evidenced by:	1 2 3 4 5 6 7	The facility states all staff will be trained regarding the regulation cited to indicate the understanding that no facility staff are permitted to be power of attorney for any resident. Proof of completion of training to be submitted to CCL by POC date 5/31/2022.
	8 9 10 11 12 13 14	The licensee did not met this requirement as evidenced by review of R1's record which revealed S1 obtained power of attorney for R1. Additionally, S1 confirmed being the power of attorney for R1 during LPA interview. This poses a potential health, safety, and personal rights risk to residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Deborah Mullen	TELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Tricia Danielson	TELEPHONE: (951) 565-7254
LICENSING EVALUATOR SIGNATURE:	DATE: 05/18/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2022

LIC9099 (FAS) - (06/04)

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