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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336410270
Report Date: 11/22/2022
Date Signed: 11/22/2022 04:39:34 PM


Document Has Been Signed on 11/22/2022 04:39 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 COTTAGEFACILITY NUMBER:
336410270
ADMINISTRATOR:ROSALYNNE VALIENTEFACILITY TYPE:
740
ADDRESS:330 S. SAN JACINTO STTELEPHONE:
(951) 765-1840
CITY:HEMETSTATE: CAZIP CODE:
92543
CAPACITY:14CENSUS: 13DATE:
11/22/2022
TYPE OF VISIT:OfficeUNANNOUNCEDTIME BEGAN:
03:05 PM
MET WITH:Licensee Victoria SarsonTIME COMPLETED:
04:45 PM
NARRATIVE
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Deborah Mullen, Licensing Program Manager and Tricia Danielson, Licensing Program Analyst (LPA) conducted an office meeting with Licensee Victoria Sarson to discuss the findings of a Trust Audit Report dated November 16, 2022 conducted by Community Care Licensing.

The audit revealed the following:

1. The Legacy Assisted Living was issued a rent check for $3,360 for March 2022. Resident #1(R1) was admitted to the facility on September 6, 2018 and died on March 8, 2022. R1’s rent was due on the 6th of each monthly, therefore R1 would have owed rent for 3 days in March 2022, totaling $325.16. R1’s bank records show a check dated March 2, 2022 was issued to the owner of The Legacy Assisted Living in the amount $3,360. R1’s son was the responsible party, however once R1’s son was no longer available to act as the responsible party, staff erroneously updated R1’s Identification and Emergency Information contact, listing staff Laura Suarez (S1) as the responsible party. When R1 died, the Licensee failed to notify R1's family of the resident’s death and failed to refund the overpayment of rent in the amount of $3,034.84.

2. The LIC601- Identification and Emergency Information form fraudulently indicated Suarez was R1’s relative, which she was not. In addition, staff Jovita Lozano(S2) and Latonya McVade(S3) signed as witnesses on the notary documentation when Suarez signed as R1’s Power of Attorney.

3. The Licensee failed to notify R1’s family when R1 died. R1’s family was notified by a third-party Fraud Department.

Based on the audit findings, the Administrator did not conform to applicable laws, rules and regulations therefore, the Licensee did not exercise supervision over the affairs of the licensed facility. The Licensee did not refund the March 2022 overpayment to R1's family. Staff made a false claim by indicating Suarez was R1’s relative on R1’s LIC601- Identification and Emergency Information form and Licensee failed to notify

(CONTINUED ON LIC809-C)

SUPERVISOR'S NAME: Deborah MullenTELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Tricia DanielsonTELEPHONE: (951) 565-7254
LICENSING EVALUATOR SIGNATURE:
DATE: 11/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/22/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4


Document Has Been Signed on 11/22/2022 04:39 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 11/22/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type B
12/22/2022
Section Cited
HSC
1569.652(d)

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Termination of admission agreement upon death of resident...refund of fees paid; notice of contract termination and refunds.(d) If fees are assessed while a resident’s personal property remains in a unit after the resident is deceased, a licensee shall,...provide to the resident’s responsible person...written notice of the facility’s policies regarding contract
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Licensee agrees to refund R1's family$3,034.84 and submit proof of such payment to CCL by POC due date of 12/22/2022.
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termination upon death and refunds. This requirement was not met as evidenced by: Based on record review, the Licensee did not notifiy R1's family of the contract termination and refund. R1's 3/2022 fee was overpaid $3,034.84 following their death and not refunded. This posed a potential health, safety, and personal
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rights risk to persons in care.
Request Denied
Type B
12/06/2022
Section Cited
CCR87207

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False Claims- No licensee, officer or employee of a licensee shall make or disseminate any false or misleading statement regarding the facility or any of the services provided by the facility. This requirement was not met as evidenced by:
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Licensee agrees to conduct training with all staff regarding making false or misleading statements or signtures of such. Proof of training to be submitted to CCL by POC due date of 12/6/2022.
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Based on record review, S2 and S3 falsely claimed S1 was R1's family member. S2 and S3 signed as witnesses on the notary documentation indicating S1 was R1's family member. This posed a potential health, saftey, and personal rights risk to persons 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: Deborah MullenTELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Tricia DanielsonTELEPHONE: (951) 565-7254
LICENSING EVALUATOR SIGNATURE:
DATE: 11/22/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/22/2022
LIC809 (FAS) - (06/04)
Page: 2 of 4


Document Has Been Signed on 11/22/2022 04:39 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 11/22/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/06/2022
Section Cited
CCR
87211(a)(1)(A)

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Reporting Requirements-(a) Each licensee shall furnish to the licensing agency...the following:(1) A written report ...to the licensing agency and to the person responsible for the resident...of the events specified...below. (A) Death of any resident ...from the facility. This requirement was not met as evidenced by:
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Licensee agrees to submit a written plan of keeping record of next of kin with contact information and ensuring timely notification of any resident death. Copy of written plan to be submitted to CCL by POC due date of 12/6/2022.
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Based on record review, the Licensee did not provide a written report of R1's death to R1's family. R1’s family was notified of the death by a third-party Fraud Department. This posed a potential health, safety, and personal rights risk to persons 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: Deborah MullenTELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Tricia DanielsonTELEPHONE: (951) 565-7254
LICENSING EVALUATOR SIGNATURE:
DATE: 11/22/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/22/2022
LIC809 (FAS) - (06/04)
Page: 3 of 4


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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
VISIT DATE: 11/22/2022
NARRATIVE
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(CONTINUED FROM LIC809)
R1’s family of R1’s passing. In accordance with California Code of Regulations (Title 22, Division 6, Chapter 8), the following deficiencies are being cited on the attached LIC9099-D pages.

An exit interview was conducted with Licensee Sarson and a copy of this report was provided along with Appeal Rights, and LIC811- Confidential Names List.

SUPERVISOR'S NAME: Deborah MullenTELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Tricia DanielsonTELEPHONE: (951) 565-7254
LICENSING EVALUATOR SIGNATURE:

DATE: 11/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2022
LIC809 (FAS) - (06/04)
Page: 4 of 4