336412123-1-23-2024-18-AS-JDHS-CZU2R9-20240125163708

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 336412123
Report Date: 01/23/2024
Date Signed: 01/23/2024 09:55:04 AM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE AC/SC, 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
01/10/2024 and conducted by Evaluator Kathleen Banrasavong

COMPLAINT CONTROL NUMBER: 18-AS-20240110162356

FACILITY NAME:	GRACEVILLE ESTATE		FACILITY NUMBER:	336412123
ADMINISTRATOR:	MARLON HERMOSILLA		FACILITY TYPE:	740
ADDRESS:	79870 BARCELONA DRIVE		TELEPHONE:	(760) 345-0183
CITY:	LA QUINTA	STATE: CA	ZIP CODE:	92253
CAPACITY:	0	CENSUS: 6	DATE:	01/23/2024
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Administrator, Marlon M Hermosilla		TIME COMPLETED:	10:10 AM

ALLEGATION(S):

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Facility staff failed to provide resident's responsible party with copies of records

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA), Kathleen Banrasavong made an unannounced visit to the facility to deliver findings on a complaint investigation regarding the allegation listed above. LPA met with Licensee/ Administrator, Marlon M Hermosilla and explained the purpose of the visit and the elements of the allegation. LPA Banrasavong conducted the investigation which consisted of observation, interviews with staff members, Resident’s Responsible Party, and record review.

On 01/16/2024, Community Care Licensing (CCL) received a complaint that alleged facility staff failed to provide Resident's Responsible Party with copies of records. Licensee stated the facility provides every resident and their responsible party a copy of documents prior to admissions. LPA interviewed Responsible Party (RP), which stated RP has never received any documentation pertaining to resident’s records.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Jazmond D Harris	TELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Kathleen Banrasavong	TELEPHONE: 951-248-0319
LICENSING EVALUATOR SIGNATURE:	DATE: 01/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2024

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

LIC9099 (FAS) - (06/04)

Page: 1 of 3

Control Number 18-AS-20240110162356

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: GRACEVILLE ESTATE	FACILITY NUMBER: 336412123
	VISIT DATE: 01/23/2024

NARRATIVE

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RP stated R1 passed away, but never signed any documentation pertaining to the admissions agreement, assessment, needs and service plan, and or personal rights forms. It was reported that on December, 15, 2023, RP requested to obtain documentation, via text message. During the interview with Licensee, Licensee stated that he received the text message, but did not respond or provide requested documents. During the course of the investigation, LPA requested to review Resident’s file. During the review, LPA observed that intake documents did not have either R1’s signature or Responsible Party’s signature.

Based on LPA’s observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED. This poses a health and safety and or personal rights risk to clients in care. The facility will be cited per Title 22 Regulations Division 6 pertaining to Resident Records. Regulation states that Licensee shall provide a copy of the signed and dated current admission agreement, and all subsequent signed and dated modifications, to the resident or the resident's representative, if any, immediately upon signing the admission agreement or modification. The licensee shall provide additional copies to the resident or resident’s representative upon request.

An exit interview was conducted. A copy of this report and the 9099-D was provided to the Licensee, Marlon M Hermosilla.

SUPERVISOR'S NAME: Jazmond D Harris	TELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Kathleen Banrasavong	TELEPHONE: 951-248-0319
LICENSING EVALUATOR SIGNATURE:	DATE: 01/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 18-AS-20240110162356

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: GRACEVILLE ESTATE	FACILITY NUMBER: 336412123
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/23/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 01/30/2024 Section Cited HSC 87507(e)	1 2 3 4 5 6 7	Admission Agreements: (e) The licensee shall provide a copy of the signed and dated current admission agreement, and all subsequent signed and dated modifications, to the resident or the resident's representative, if any, immediately upon signing the admission agreement or modification. The licensee shall provide additional copies to the resident or resident’s representative upon request.This requirement was not being met as evidenced by:	1 2 3 4 5 6 7	The Licensee agrees to read the regulation entirely and provide written notice to ensure that all resident records are complete, signed and up to date when maintained at the facility. This POC is due by 01/30/2024.
	8 9 10 11 12 13 14	Based on the LPA's record review, interview, the Licensee did not provide the responsible party of R1 with request resident records, as requested by the responsible party.	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: Jazmond D Harris	TELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Kathleen Banrasavong	TELEPHONE: 951-248-0319
LICENSING EVALUATOR SIGNATURE:	DATE: 01/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2024

LIC9099 (FAS) - (06/04)

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