336423877-8-19-2022-18-AS-DMUN-CHRTZF-20220829151016

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 336423877
Report Date: 08/19/2022
Date Signed: 08/19/2022 10:18:14 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
02/28/2022 and conducted by Evaluator Tricia Danielson

COMPLAINT CONTROL NUMBER: 18-AS-20220228173307

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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Staff neglect resulting in death of 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 allegations “Staff neglect resulting in death of residents”, it was alleged that four residents had been transported to the hospital between February 22 and 28, 2022 and subsequently died from septic shock. The investigation revealed two (2) residents and one (1) staff passed away. Resident #1 (R1) had only resided at the facility for approximately one (1) day prior to being sent to the hospital on January 28, 2022 after being observed to be in respiratory distress by facility staff. Review of R1’s medical documents revealed R1 passed away from a combination of prior medical complications. The investigation revealed no evidence that the facility was neglectful in providing care for R1. To the contrary, when R1 was observed to be in distress, the facility activated emergency medical services right away. Review of R1’s hospital records revealed no indication of signs of abuse or neglect upon arrival to the hospital. (CONTINUED ON LIC 9099C)

Unsubstantiated

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-20220228173307

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)
Resident #2 (R2) had only resided at the facility for ten (10) days prior to being sent to the hospital on February 18, 2022 after being observed with breathing difficulties. Review of R2’s medical documents revealed R2 passed away from aspiration pneumonia. The investigation revealed no evidence that the facility was neglectful in providing care for R2. To the contrary, when R2 was observed to be experiencing difficulties, the facility activated emergency medical services right away. Review of R2’s hospital records revealed no indication of signs of abuse or neglect upon arrival to the hospital.

The above allegations are found to be UNSUBSTANTIATED. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated at this time.
An exit interview was conducted and a copy of this report along with LIC 811- Confidential Names list was provided.

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

LIC9099 (FAS) - (06/04)

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