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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 336412255
Report Date: 10/12/2021
Date Signed: 10/12/2021 03:10:04 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
07/20/2021 and conducted by Evaluator Crystal Colvin
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20210720165959
FACILITY NAME:LIFESTYLE HOME CARE IIFACILITY NUMBER:
336412255
ADMINISTRATOR:MARY MATEASFACILITY TYPE:
740
ADDRESS:5417 SKYLOFT DRIVETELEPHONE:
(951) 360-1622
CITY:RIVERSIDESTATE: CAZIP CODE:
92509
CAPACITY:6CENSUS: 5DATE:
10/12/2021
UNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Mary Mateas - Licensee/AdministratorTIME COMPLETED:
03:15 PM
ALLEGATION(S):
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Staff yelled at resident
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Crystal Colvin arrived at the facility unanounced in order to deliver findings on the investigation of a complaint with the above allegation(s). LPA Colvin identified herself and discussed the purpose of the visit with Licensee/Administrator Mary Mateas. Below are the findings of the investigation:

Staff yelled at resident: LPA Colvin reviewed resident records and conducted interviews with staff, residents, and relevant outside parties. During LPA Colvin's investigation, LPA Colvin was informed that Licensee/Administrator Mary Mateas yelled at Resident 1 (R1) on mulitple occasions, including in the presence of others. According to interviews conducted, the yelling primarily occured when R1 and the Licensee would be arguing over aspects of R1's care. Due to interviews conducted, the allegation "Staff yelled at resident" 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. An exit interview was conducted where this report and appeal rights were discussed. A copy of this report, LIC9099D, and appeal rights were provided to Licensee/Administrator Mary Mateas, who refused to sign the report.
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: 10/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2021
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-20210720165959
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: LIFESTYLE HOME CARE II
FACILITY NUMBER: 336412255
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/12/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/13/2021
Section Cited
CCR
87468.1(a)(1)
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Personal Rights of Residents in All Facilities: (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (1) To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement was not met by:
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Licensee agrees to do additional training regarding Resident Personal Rights. Licensee to submit proof of training to LPA Colvin by Plan of Correction date.
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Based on interviews, the Licensee did not comply with the above regulation with at least one resident (R1). Interviews revealed that on multiple occasions Licensee Mary Mateas yelled at R1. This was an immediate personal rights violation of R1.
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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: 10/12/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2021
LIC9099 (FAS) - (06/04)
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