336410274-7-7-2020-18-AS-JESL-BU4RL2-20201005130625

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 336410274
Report Date: 07/07/2020
Date Signed: 07/07/2020 03:20:42 PM

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
05/07/2020 and conducted by Evaluator David Cuevas

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20200507145843

FACILITY NAME:	CHRISTMAS COTTAGE		FACILITY NUMBER:	336410274
ADMINISTRATOR:	VICTORIA J. SARSON		FACILITY TYPE:	740
ADDRESS:	320 S. SAN JACINTO ST		TELEPHONE:	(951) 765-1840
CITY:	HEMET	STATE: CA	ZIP CODE:	92543
CAPACITY:	17	CENSUS: 10	DATE:	07/07/2020
		UNANNOUNCED	TIME BEGAN:	02:30 PM
MET WITH:	Licensee, Victoria J. Sarson		TIME COMPLETED:	03:15 PM

ALLEGATION(S):

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Facility is not feeding resident

INVESTIGATION FINDINGS:

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On July 7, 2020 Licensing Program Analyst (LPA) David Cuevas contacted the facility unannounced via telephone due to COVID-19 to deliver findings for complaint investigation, case # 18-AS-20200507145843. LPA identified self and discussed the purpose of the call and the elements of the allegation with Administrator, Victoria J. Sarson.

Regarding Allegation: Facility is not feeding resident

During previous tele visit to facility LPA conducted interviews with staff members and requested copies of pertinent documents in resident #1 (R1’s) file. Based on the collected evidence and interviews, it was discovered that R1 was receiving hospice services and comfort care while living at the facility. Resident record review identified R1 to have arrived at the facility in poor condition with hospital discharge records reflecting R1 to have been at a “high risk of rapid deterioration”. Medical records reviewed reflect R1 to have, “not been eating or drinking well and refusing to take pain medication” prior to living at facility.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 836-2784
LICENSING EVALUATOR NAME: David Cuevas	TELEPHONE: (951) 295-3927
LICENSING EVALUATOR SIGNATURE:	DATE: 07/07/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2020

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-20200507145843

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: 336410274
	VISIT DATE: 07/07/2020

NARRATIVE

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Thus, the need for resident to be in hospice. During interviews with staff members it was reported to LPA that R1’s appetite was good when first arrived at the facility; however, as R1’s condition progress food and fluid intake diminished. Per Interviews with staff and review of fluid and food intake charts LPA observed R1 to have refused food and water in several occasions. In addition, through interviews and review of resident care plan it appeared that when R1 would refuse to eat, facility would provide, “meal replacement supplements” as alternative. As such, allegation of: Facility is not feeding resident is UNSUBSTANTIATED.

A finding that is UNSUBSTANTIATED means that although the allegation may have happened or is valid, there is not enough preponderance of evidence to prove the allegation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

An exit interview was conducted with Administrator, Victoria J. Sarson. via telephone and a copy of this report was provided via email. Report with facility representative signature requested.

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 836-2784
LICENSING EVALUATOR NAME: David Cuevas	TELEPHONE: (951) 295-3927
LICENSING EVALUATOR SIGNATURE:	DATE: 07/07/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2020

LIC9099 (FAS) - (06/04)

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