336412698-9-22-2020-18-AS-RLAY-BTSR5D-20200925124258

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 336412698
Report Date: 09/18/2020
Date Signed: 09/22/2020 11:10:47 AM

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
06/17/2020 and conducted by Evaluator Pauline Beschorner

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20200617103952

FACILITY NAME:	AFFINITY SENIOR LIVING 2		FACILITY NUMBER:	336412698
ADMINISTRATOR:	ESTHER CRUZ		FACILITY TYPE:	740
ADDRESS:	28200 HORIZON ROAD		TELEPHONE:	(760) 864-3259
CITY:	CATHEDRAL CITY	STATE: CA	ZIP CODE:	92234
CAPACITY:	9	CENSUS: 7	DATE:	09/18/2020
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Ana Lisa Cayabyab		TIME COMPLETED:	12:00 PM

ALLEGATION(S):

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Staff is denying resident use of a urinal.
Staff is not assisting resident with activities of daily living.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Pauline Beschorner conducted this investigation visit telephonically due to Covid-19 to conclude this agency’s investigation into the complaint allegations mentioned above. LPA spoke with Administrator Ana Lisa Cayabyab.

During this investigation, interviews were conducted with the Administrator, staff and other pertinent witnesses. Resident’s (R1 and R2) physician reports were obtained and reviewed. R1 and R2 were unable to be interviewed due to cognitive impairments.

The first allegation states that the facility staff are denying resident use of a urinal. Interviews with the administrator, staff and other pertinent witnesses stated that R1 needs assistance getting to the restroom but will sometimes have accidents in the adult diaper. R1 is in denial that an adult diaper is needed and at times blame a wet bed on someone coming into R1’s bed and having an accident. CONTINUED ON NEXT PAGE

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Pauline Beschorner	TELEPHONE: (951) 897-7936
LICENSING EVALUATOR SIGNATURE:	DATE: 09/18/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2020

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-20200617103952

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: AFFINITY SENIOR LIVING 2	FACILITY NUMBER: 336412698
	VISIT DATE: 09/18/2020

NARRATIVE

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According to R1’s physician report R1 has a bladder impairment. Adult diapers are bought and delivered on a regular basis for use when R1 cannot make it to the restroom.

The second allegation states that staff are not assisting resident with activities of daily living. Interviews with staff revealed that R1 needs assistance with some activities of daily living but not with all activities. Interviews revealed that R1 has a specific schedule that R1 will follow and does not like to be swayed from the schedule because of R1 and R2’s cognitive impairments. Interviews with staff revealed that staff will wait for R1 to call for facility staff in the morning before staff go into the room to assist R1 and R2 as R1 does not like to be disturbed prior to a specific time of day. When R1 tells staff R1 needs something staff will immediately assist to avoid R1 getting agitated. Interviews with pertinent witnesses confirmed the information provided by facility staff.

Based on the information obtained there is not enough evidence that staff are denying resident use of urinal or that staff is not assisting resident with activities of daily living. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

An exit interview was conducted, and a copy of this report was reviewed with and provided to Administrator Ana Lisa Cayabyab, whose signature on this form confirm receipt of the above-mentioned documents.

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Pauline Beschorner	TELEPHONE: (951) 897-7936
LICENSING EVALUATOR SIGNATURE:	DATE: 09/18/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2020

LIC9099 (FAS) - (06/04)

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