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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 336410270
Report Date: 02/02/2023
Date Signed: 02/02/2023 02:41:25 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
06/16/2020 and conducted by Evaluator Venus Mixson
COMPLAINT CONTROL NUMBER: 18-AS-20200616091243
FACILITY NAME:CHRISTMAS COTTAGEFACILITY NUMBER:
336410270
ADMINISTRATOR:VICTORIA J. SARSONFACILITY TYPE:
740
ADDRESS:330 S. SAN JACINTO STTELEPHONE:
(951) 765-1840
CITY:HEMETSTATE: CAZIP CODE:
92543
CAPACITY:14CENSUS: 14DATE:
02/02/2023
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:FACILITY MANAGER, KATHLEEN HYLAND..TIME COMPLETED:
02:50 PM
ALLEGATION(S):
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Resident wandered away from the facility while in care.
INVESTIGATION FINDINGS:
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Resident wandered away from the facility while in care.

On February 02, 2023, Licensing Program Analyst (LPA), Venus Mixson conducted a visit to the above facility and met with Facility Manager introduced self and stated the purpose of the visit.

The visit was conducted in order to provide findings for the investigation pertaining to the above allegation. During the investigation, LPA Mixson conducted interviews, and record reviews.

On June 16, 2022, Community Care Licensing received information that Resident (R1), wandered away from the facility while in care. Information obtained through LPA's interviews stated that the R1 left the facility for about two hours and that Hemet Police Department located the Resident and released to the Facility Staff.

Based upon the investigation the allegation that resident wandered away from the facility while in care is substantiated and in accordance with Title 22 Regulations, Section 87705, a citation is being issued.

The preponderance of evidence standard has been met and an allegation of SUBSTANTIATED was concluded. A finding of SUBSTANTIATED means the preponderance of evidence standard has been met.

An exit interview was conducted with Facility Manager and a copy of this report, along with Appeals rights and plan of correction was provided to the Facility Manager.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Jazmond D HarrisTELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Venus MixsonTELEPHONE: (951) 897-7936
LICENSING EVALUATOR SIGNATURE:

DATE: 09/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2022
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-20200616091243
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: 02/02/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/15/2023
Section Cited
CCR
87705
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Care of Persons with DementiaThis section applies to licensees who accept or retain residents diagnosed by a physician to have dementia. Mild cognitive impairment, as defined in Section 87101(m), is not considered to be dementia.
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Administrator agrees to retrain all staff on regulations section 87705 and supervision of Persons with Dementia.
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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: Jazmond D HarrisTELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Venus MixsonTELEPHONE: (951) 897-7936
LICENSING EVALUATOR SIGNATURE:

DATE: 02/02/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/02/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2