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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336410270
Report Date: 06/29/2023
Date Signed: 06/29/2023 09:56:35 AM


Document Has Been Signed on 06/29/2023 09:56 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 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: 11DATE:
06/29/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Kay Hyland, ManagerTIME COMPLETED:
10:00 AM
NARRATIVE
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Licensing Program Analyst (LPA) Tricia Danielson arrived unannounced to the facility to conduct a case management visit in conjunction with complaint control #18-AS-20220322141019. LPA met with Manager Kay Hyland and explained the purpose of the visit.

On 11/22/2022, an office visit was conducted with Licensee Victoria Sarson and LIC9099D dated 11/22/2022 was issued. The LIC9099D documented a deficiency for a substantiated finding of the allegation "Staff mismanaged resident funds". The purpose of today's visit is to amend the plan of correction for the deficiency. During today's visit, LPA and Hyland discussed a new plan of correction. The attached LIC809D documents the updated plan of correction.

An exit interview was conducted and a copy of this report was provided along with LIC811- Confidential Names list and Appeal Rights.
SUPERVISOR'S NAME: Jazmond D HarrisTELEPHONE: (951) 782-4807
LICENSING EVALUATOR NAME: Tricia DanielsonTELEPHONE: (951) 565-7254
LICENSING EVALUATOR SIGNATURE:
DATE: 06/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/29/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/29/2023 09:56 AM - 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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507


FACILITY NAME: CHRISTMAS COTTAGE
FACILITY NUMBER: 336410270

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/29/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/30/2023
Section Cited
HSC
1569.269(a)(10)

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1569.269(a)(10) Enumerated rights; severability- (a)Residents of residential care facilities for the elderly shall have all of the following rights:(10)To be free from neglect, financial explotation... intimidation, and verbal, mental, physical ...abuse. This requirement was not met as evidenced by:
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The facility will implement a quarterly review of all resident's files to ensure no staff is listed as POA or is listed as financially or medically responsible for any resident. All staff will sign an agreement that they understand they are not permitted to be a POA or financially .
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Based on record review, the Licensee did not ensure R1 was free from financial exploitation while under the facility's care. S1 fraudulently utilized R1’s funds for personal use. This poses a potential health, safety and personal rights risk to residents in care.
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or medically responsible for any resident.

A written policy of this procedure will be submitted to CCL by 6/30/2023.

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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) 782-4807
LICENSING EVALUATOR NAME: Tricia DanielsonTELEPHONE: (951) 565-7254
LICENSING EVALUATOR SIGNATURE:
DATE: 06/29/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/29/2023
LIC809 (FAS) - (06/04)
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