336423521-3-27-2023-18-AS-NBRN-CR8UN8-20230425154328

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 336423521
Report Date: 03/27/2023
Date Signed: 03/27/2023 01:01:44 PM

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
, CA 92507

This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/27/2022 and conducted by Evaluator Amy Goldenberg

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20220127143345

FACILITY NAME:	ABBEY ELDER CARE, INC.		FACILITY NUMBER:	336423521
ADMINISTRATOR:	SUNDEEP RANDHAWA		FACILITY TYPE:	740
ADDRESS:	3412 WEXFORD CIRCLE		TELEPHONE:	(951) 858-8641
CITY:	CORONA	STATE: CA	ZIP CODE:	92882
CAPACITY:	6	CENSUS: 5	DATE:	03/27/2023
		UNANNOUNCED	TIME BEGAN:	12:15 PM
MET WITH:	Alma Guzman, Caregiver		TIME COMPLETED:	01:15 PM

ALLEGATION(S):

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-Wrongful eviction.
-Resident's special dietary needs are not being met.
-Resident is being spoken to inappropriately while in care.
-Admission's Agreement was not completed within the required time.
-Resident's requests for assistance are not being responded to in a timely manner.
-COVID-19 safety protocols are not being adhered to.
-Resident was not accorded privacy while in care.
-Resident is being served spoiled food while in care.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Amy Goldenberg is conducting this unannounced visit to conclude investigation into the above-mentioned complaint allegations. LPA met with caregiver Alma Guzman and reviewed the complaint investigation findings.

During the course of this investigation interviews were conducted with staff and residents, a review of resident record for R1 for dietary orders, admission agreement, and eviction notification. LPA reviewed house rules and Title 22 section 87224, Eviction Procedures. LPA received copies of pertinent documents. LPA reviewed the facility menus, checked the food supply and reviewed the facility COVID-19 mitigation plan, sign in and visitor policies. Investigation revealed the following:

It is alleged R1 was given an eviction notice on January 11th, 2022 because she called staff names and threw a rag/towel at a staff member. LPA obtained a copy of an eviction notice dated 1/11/2023 and confirmed that an eviction letter was written.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Amy Goldenberg	TELEPHONE: (951) 201-3990
LICENSING EVALUATOR SIGNATURE:	DATE: 03/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2023

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-20220127143345

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
, CA 92507

FACILITY NAME: ABBEY ELDER CARE, INC.	FACILITY NUMBER: 336423521
	VISIT DATE: 03/27/2023

NARRATIVE

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When interviewed the licensee stated that the eviction letter was never provided to R1 and that R1 decided to move on their own. An admission agreement was present in the record. Within that admission agreement notification of the house rules are present and list violation grounds for eviction which includes verbal or physical abuse directed towards other residents or staff. R1 reported receiving an eviction letter and in accordance to the house rules the reason for the eviction would not have been wrongful, however, interview with the licensee reports that R1 left on their own accord and did not deliver the eviction notice to R1.

R1 reports being on a special diet prescribed by her doctor and has been fed spoiled food and has suffered food poisoning from it. LPA review of R1’s record does not reveal any special diet orders. Interviews with staff revealed that all of R1’s foods are prepared by their mother and delivered to the facility. R1 had their own refrigerator freezer in the garage to store their own meals. Interviews with staff revealed that R1 would request their food through writing notes or text to staff. R1 reports that meals are often missing certain components and that refrigerated probiotics are left in their room sitting there for a half hour and is not being provided utensils. Staff interviewed report that they provided R1 with requested foods and are unaware of serving R1 spoiled foods or leaving foods out for extended periods of time prior to serving to R1. According to staff R1 will specify what utensils they want and staff will wrap them up in a napkin and put them on the serving tray for R1. Three (3) of three (3) residents interviewed do not have concerns about the food they receive.

It is alleged that R1 is being spoken to inappropriately while in care. LPA reviewed incident reports dated 01/01/2022, 01/10/2022, 01/24/2022 which report R1’s verbal abuse toward staff. Interview with R2, a resident in a room that shares a common wall with R1, reported that they overhear R1 often yelling at staff. R2 denies overhearing staff yelling at R1. Staff interviewed deny speaking inappropriately to R1.

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Amy Goldenberg	TELEPHONE: (951) 201-3990
LICENSING EVALUATOR SIGNATURE:	DATE: 03/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 3

Control Number 18-AS-20220127143345

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
, CA 92507

FACILITY NAME: ABBEY ELDER CARE, INC.	FACILITY NUMBER: 336423521
	VISIT DATE: 03/27/2023

NARRATIVE

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(Page 3 of 3)

R1 alleges that they were never provided with an admission agreement to sign. An admission agreement was present in the record but was not signed. Interview with S1 indicated that the admission agreement was presented to R1 at the time of admission and several times after admission but R1 refused to sign the admission agreement, citing that they are too sick to do the paperwork. Record review does not reveal unsigned admission agreements on three (3) of four (4) resident records reviewed.

It is alleged that staff did not respond timely to R1’s request to clean their commode on 01/26/2022. Staff interviewed deny refusing care to R1. Three (3) of Three (3) residents interviewed report that staff take good care of them.

It is alleged that staff allowed a visitor from a placement agency into R1s room without a mask. Interviews were conducted with staff and staff report that if visitors come to see R1 that they are requested to wear a mask and per R1’s request also gloves. R1 provided N95 and gloves for everyone that enters their room according to the staff interviewed. Three (3) of Three (3) residents interviewed report their visitors wear masks.

It is alleged that staff allowed a visitor into R1’s room unannounced. Staff interviews revealed that R1 has a lock on their door. Staff and visitors are requested to knock prior to entrance into any resident room as a facility practice according to staff interviewed. Staff do not recall anyone walking into R1’s room without knocking prior to entry. Three (3) of Three (3) residents interviewed do not have any problems with unexpected visitors.

Based on conflicting information received, we have found the complaint allegation is unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

A copy of this report is being reviewed with and furnished to the facility representative.

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Amy Goldenberg	TELEPHONE: (951) 201-3990
LICENSING EVALUATOR SIGNATURE:	DATE: 03/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2023

LIC9099 (FAS) - (06/04)

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