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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 336412123
Report Date: 02/01/2023
Date Signed: 02/01/2023 02:07:56 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
01/27/2023 and conducted by Evaluator Crystal Colvin
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20230127145652
FACILITY NAME:GRACEVILLE ESTATEFACILITY NUMBER:
336412123
ADMINISTRATOR:MARLON HERMOSILLAFACILITY TYPE:
740
ADDRESS:79870 BARCELONA DRIVETELEPHONE:
(760) 345-0183
CITY:LA QUINTASTATE: CAZIP CODE:
92253
CAPACITY:6CENSUS: 6DATE:
02/01/2023
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Marlon Hermosila - AdministratorTIME COMPLETED:
02:15 PM
ALLEGATION(S):
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Staff did not provide resident records to resident and/or resident's legal representative
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Colvin arrived at the facility unannounced for the purpose of investigating this complaint. LPA Colvin met with facility staff and informed them of the purpose of today's inspection. Below is a summary of the findings:

Regading allegation "Staff did not provide resident records to resident and/or resident's legal representative": LPA Colvin received a detailed record from Titan Legal Services regarding attempts to contact the Administrator for release of records since 1/16/23, including a letter with release from the family for legal services to receive records. LPA Colvin spoke with Administrator Marlon Hermosila, who admitted that he had been contacted, but was waiting to hear back from the family. Based on record review and interviews, the allegation is SUBSTANTIATED.

A finding that the complaint is SUBSTANTIATED means that the allegation(s) is valid because the preponderance of the evidence standard has been met.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Crystal ColvinTELEPHONE: (951) 204-0848
LICENSING EVALUATOR SIGNATURE:

DATE: 02/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/01/2023
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-20230127145652
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: GRACEVILLE ESTATE
FACILITY NUMBER: 336412123
VISIT DATE: 02/01/2023
NARRATIVE
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Due to observations made by LPA Colvin, the facility was cited and deficiencies noted on LIC 9099 D. An exit interview was conducted where this report and appeal rights were discussed. A copy this report, LIC 9099D, and appeal rights were provided to Administrator Marlon Hermosila during the exit interview.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Crystal ColvinTELEPHONE: (951) 204-0848
LICENSING EVALUATOR SIGNATURE:

DATE: 02/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/01/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 18-AS-20230127145652
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: GRACEVILLE ESTATE
FACILITY NUMBER: 336412123
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/01/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/02/2023
Section Cited
CCR
87468.2(a)(19)
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 (a) In addition to the rights listed .... shall have all of the following personal rights: (19) To have prompt access to review all of their records ...shall be provided within two (2) business days and at a cost that does not exceed the community standard for photocopies. This was not met by:
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Licensee agrees to release records to the family's representative withint 24 hours. Licensee may self-certify to LPA Colvin once complete.
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The Licensee did not comply with the above regulation with at least one resident (R1). R1's family representative has been requesting recoeds for over two weeks with no success. This is an immediate violation of R1's personal rights.
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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: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Crystal ColvinTELEPHONE: (951) 204-0848
LICENSING EVALUATOR SIGNATURE:

DATE: 02/01/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/01/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3