336412798-7-20-2021-18-AS-RSTS-DDEQ3G-20250130104844

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 336412798
Report Date: 07/20/2021
Date Signed: 07/20/2021 11:52:16 AM

Unsubstantiated

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
07/12/2021 and conducted by Evaluator Stephanie Torres

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20210712100443

FACILITY NAME:	AFFINITY SENIOR LIVING 1		FACILITY NUMBER:	336412798
ADMINISTRATOR:	ANALISA CAYABYAB		FACILITY TYPE:	740
ADDRESS:	68842 RISUENO ROAD		TELEPHONE:	(760) 322-7905
CITY:	CATHEDRAL CITY	STATE: CA	ZIP CODE:	92234
CAPACITY:	10	CENSUS: 8	DATE:	07/20/2021
		UNANNOUNCED	TIME BEGAN:	09:50 AM
MET WITH:	Analisa Cayabyab, Administrator		TIME COMPLETED:	11:50 PM

ALLEGATION(S):

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Staff do not prevent a resident from causing harm to other residents while in care

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA), Stephanie Torres, conducted an unannounced visit to the facility to initiate the investigation into the above allegation. The LPA was greeted by staff, Gloria Antonio, and informed her of the purpose of the visit. Administrator, Analisa Cayabyab, was contacted via telephone and informed of the purpose of the visit.

Pertaining to the allegation, "Staff do not prevent resident from causing harm to other residents in care," it was alleged Resident Two (R2) is casing harm to Resident One (R1) by harassing them. R1 was interviewed and reported R2 harasses them by making threats to come into their bedroom without permission, and does successfully make entry. R1 reported R2 has not hurt them or other residents in care. R2 was interviewed and could not provide a statement on the allegation. Administrator Cayabyab was interviewed and reported R2 is new to the facility and is orienting themself to the home. She reported R2 has gone into R1s bedroom, though is looking for the bathroom. Staff interviews were conducted; it was reported R2 has gone into R1's bedroom, though is quickly redirected. Staff reported R2 does not make threats to come into R1's bedroom without

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Stephanie Torres	TELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:	DATE: 07/20/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2021

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-20210712100443

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 1	FACILITY NUMBER: 336412798
	VISIT DATE: 07/20/2021

NARRATIVE

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permission. Resident interview was conducted; it was reported no resident comes into their bedroom without permission or threatens to do so. Therefore, this allegation is deemed UNSUBSTANTIATED at this time. A finding that the complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

This report was reviewed with Administrator Cayabyab and a copy was provided via email.

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Stephanie Torres	TELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:	DATE: 07/20/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2021

LIC9099 (FAS) - (06/04)

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