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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 336423324
Report Date: 06/08/2022
Date Signed: 06/08/2022 10:12:02 AM

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
06/01/2022 and conducted by Evaluator Stephanie Torres
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20220601122137
FACILITY NAME:PARTNERS N CARE SENIOR RESIDENCEFACILITY NUMBER:
336423324
ADMINISTRATOR:BEVERLEE VAUGHANFACILITY TYPE:
740
ADDRESS:5873 BUD COURTTELEPHONE:
(951) 213-6314
CITY:RIVERSIDESTATE: CAZIP CODE:
92506
CAPACITY:6CENSUS: 4DATE:
06/08/2022
UNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Karin Vaughan, House ManagerTIME COMPLETED:
10:20 AM
ALLEGATION(S):
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Resident was denied visitors
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 met with House Manager, Karin Vaughan, and informed her of the purpose of her visit.

The LPA initiated the investigation on this date; staff interview was conducted, records were reviewed, and copies of pertinent documenation were obtained. Pertaining to the allegation, "Resident was denied visitors," it was alleged a visit from a family member with Resident One (R1) had been denied by facility staff on or around May 21, 2022. Staff interview revealed family visits with R1 were denied on or around May 08, 2022 and May 14, 2022. An interview with R1 could not be conducted, as the resident passed away on May 25, 2022. Staff interview reported R1 neither requested nor denied to visit with these individuals. Interview reported R1's designated representative requested visits be restricted for R1. However, no court order showing restrictions to visits for R1 was observed on file. Therefore, this allegation is deemed SUBSTANTIATED. A finding that the complaint is substantiated means that the allegation is valid because the preponderance of

Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Deborah MullenTELEPHONE: (951) 248-0313
LICENSING EVALUATOR NAME: Stephanie TorresTELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:

DATE: 06/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/08/2022
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-20220601122137
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: PARTNERS N CARE SENIOR RESIDENCE
FACILITY NUMBER: 336423324
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/08/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/15/2022
Section Cited
CCR
87468.1(a)(11)
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Personal Rights of Residents in All Facilities: Residents in all RCFEs shall have all of the following personal rights: To have their visitors...permitted to visit privately during reasonable hours and without prior notice, provided that the rights of other residents are not infringed upon. This requirement was
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The House Manager stated the visitor's policy would be ammended and updated, and submitted to the Department by POC date.
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not met, as evidenced by: Based on interview, family visits with R1 were denied. No court order indicating family visits could be restricted was observed on file. This posed a potential threat to the personal rights 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: Deborah MullenTELEPHONE: (951) 248-0313
LICENSING EVALUATOR NAME: Stephanie TorresTELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:

DATE: 06/08/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/08/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 18-AS-20220601122137
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: PARTNERS N CARE SENIOR RESIDENCE
FACILITY NUMBER: 336423324
VISIT DATE: 06/08/2022
NARRATIVE
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the evidence standard has been met. A citation will be issued in accordance with the California Code of Regulations (Title 22, Division 6, Chapter 8).

An exit interview was conducted with Vaughan; this report was reviewed and a copy was provided, along with the Appeal Rights.
SUPERVISOR'S NAME: Deborah MullenTELEPHONE: (951) 248-0313
LICENSING EVALUATOR NAME: Stephanie TorresTELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:

DATE: 06/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/08/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3