336423877-8-19-2022-18-AS-DMUN-CHRTYH-20220829150845

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 336423877
Report Date: 08/19/2022
Date Signed: 08/19/2022 10:29:01 AM

Unfounded

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
02/22/2022 and conducted by Evaluator Tricia Danielson

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20220222165720

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:	0	CENSUS: 0	DATE:	08/19/2022
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Melayna Lagasca, Caregiver		TIME COMPLETED:	10:30 AM

ALLEGATION(S):

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Facility is not able to provide appropriate care and supervision to residents.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Tricia Danielson arrived unannounced to the facility to conclude a complaint investigation into the allegation noted above. LPA met with Caregiver Melayna Lagasca and explained the purpose of the visit.
Regarding the allegation “Facility is not able to provide appropriate care and supervision to residents”, it was alleged that four (4) residents had been transported to the hospital within three (3) days after being found unresponsive with elevated blood pressures. It was further alleged that it was unusual to have four (4) residents exhibit the same symptoms in such a short period of time. Also alleged was that one of the residents had been providing care for the other residents.
The investigation revealed two (2) residents and one (1) staff were sent to the hospital. Resident #1 (R1) had exhibited signs of respiratory distress and facility staff activated emergency services as a result. It was later determined at the hospital that R1 was suffering from complications of prior medical conditions. Resident #2 (R2) had been observed with breathing difficulties and staff activated emergency services as well. It was later deteremined at the hospital that R1 had aspiration pneumonia. (CONTINUED ON LIC 9099C)

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Deborah Mullen	TELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Tricia Danielson	TELEPHONE: (951) 565-7254
LICENSING EVALUATOR SIGNATURE:	DATE: 08/19/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2022

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-20220222165720

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: 08/19/2022

NARRATIVE

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(CONTINUED FROM LIC9099)
The investigation revealed no evidence that the facility was not providing appropriate care and supervision to the residents. To the contrary, facility staff made immediate observations and summoned emergency personnel without hesitation. Finally, the resident who was alleged to have been providing care to other residents was in fact the Licensee/Administrator of the facility.
This agency has investigated the complaint alleging "Facility is not able to provide appropriate care and supervision to residents". We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. An exit interview was conducted and a copy of this report was provided along with LIC 811- Confidential Names List.

SUPERVISOR'S NAME: Deborah Mullen	TELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Tricia Danielson	TELEPHONE: (951) 565-7254
LICENSING EVALUATOR SIGNATURE:	DATE: 08/18/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2022

LIC9099 (FAS) - (06/04)

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