336423877-6-21-2021-18-AS-KCLS-C4FUUB-20210629155315

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 336423877
Report Date: 06/21/2021
Date Signed: 06/21/2021 10:53:04 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
06/16/2021 and conducted by Evaluator Christine Le

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20210616112535

FACILITY NAME:	FOR HIS GRACE SENIOR CARE HOME		FACILITY NUMBER:	336423877
ADMINISTRATOR:	MANUEL LAGASCA		FACILITY TYPE:	740
ADDRESS:	12537 POINSETTA DRIVE		TELEPHONE:	(951) 689-0182
CITY:	RIVERSIDE	STATE: CA	ZIP CODE:	92503
CAPACITY:	6	CENSUS: 3	DATE:	06/21/2021
		UNANNOUNCED	TIME BEGAN:	09:10 AM
MET WITH:	Manuel Lagasca		TIME COMPLETED:	11:01 AM

ALLEGATION(S):

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Resident is being mistreated while in care
Staff is threatening a resident with eviction while in care
Staff is interfering with a resident's hospice needs
Resident is not allowed visitors

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPAs) Christine Le and Anna Bueno conducted an unannounced visit to the facility to investigate the above allegations. LPAs met with administrator Manuel Lagasca.

LPAs toured the facility, conducted interviews, and reviewed files. During the investigation, LPAs were informed by an outside party that the allegations for this complaint have been resolved and/or found to be not true. The first allegation indicates that Resident 1 (R1) is being mistreated while in care. LPAs conducted interviews with staff and R1 and in general it was reported that the staff take good care of the residents and there are no reports of physical or mental abuse. The second allegation indicates that the staff is threatening a resident with eviction while in care. The administrator denied this and advised that an eviction notice was not issued. Information from the outside party also confirmed this. The third allegation indicates that the staff are interfering with R1's hospice needs and tried to change the hospice agency. LPAs were informed that R1 is on hospice. LPAs were informed that the administrator and R1's family were in discussion with switching R1's hospice agency. LPAs observed that R1's family signed the new hospice

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Christine Le	TELEPHONE: (951) 897-2618
LICENSING EVALUATOR SIGNATURE:	DATE: 06/21/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2021

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-20210616112535

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: FOR HIS GRACE SENIOR CARE HOME	FACILITY NUMBER: 336423877
	VISIT DATE: 06/21/2021

NARRATIVE

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agency paperwork. An interview with the administrator denied changing R1's hospice agency without R1's permission. Information from the outside party also confirmed this. LPAs were informed that R1 did not end up changing hospice agencies and is still receiving services from the original agency. The fourth allegation indicates that the R1 is not allowed visitors. Information from the outside party denied this. LPAs were informed that the residents are allowed visitors and can contact the administrator to schedule them.

This agency has investigated the complaint allegation. We have found that the complaint was unfounded meaning that the allegations were false, could not have happened and/or are without a reasonable basis.

No deficiencies were cited during this visit. An exit interview was conducted where this report was discussed and provided to the administrator.

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Christine Le	TELEPHONE: (951) 897-2618
LICENSING EVALUATOR SIGNATURE:	DATE: 06/21/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2021

LIC9099 (FAS) - (06/04)

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