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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 336424396
Report Date: 11/04/2021
Date Signed: 11/04/2021 03:24:25 PM

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
10/29/2021 and conducted by Evaluator Crystal Colvin
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20211029114555
FACILITY NAME:SEGOVIA OF PALM DESERTFACILITY NUMBER:
336424396
ADMINISTRATOR:ERNIE SHAFFERFACILITY TYPE:
741
ADDRESS:39905 VIA SCENATELEPHONE:
(760) 674-3200
CITY:PALM DESERTSTATE: CAZIP CODE:
92260
CAPACITY:182CENSUS: 153DATE:
11/04/2021
UNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Ernie Shaffer - Executive Director/AdministratorTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Staff confiscated resident's personal property
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Crystal Colvin arrived at the facility unannounced in order to initiate an investigation of a complaint with the above allegation(s). LPA identified herself and discussed the purpose of the visit and the elements of the allegation(s) with Executive Director/Administrator Ernie Shaffer. Below is a summary of the complaint investigation findings:

Regarding allegation "Staff confiscated resident's personal property": LPA Colvin interviewed staff and residents relevant to the allegation. During LPA Colvin's interviews, Executive Director/Administrator Ernie Shaffer stated that when a Cease and Desist letter was posted on a resident's (R2's) door, the Administrator removed the posting due to instruction from the facility's legal counsel. Shaffer stated that there was also a letter in a sealed envelope taped to the door, which they slipped under the door. Shaffer believed that this was a copy of the posting, but this could not be guaranteed as the envelope was sealed and the posting did not state that an envelope of with the same communication was tape to the door as well. The posting on R1's door was a notice of potential legal action; which Shaffer took it upon themselves to remove.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Crystal ColvinTELEPHONE: (951) 204-0848
LICENSING EVALUATOR SIGNATURE:

DATE: 11/04/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2021
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 7
Control Number 18-AS-20211029114555
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: SEGOVIA OF PALM DESERT
FACILITY NUMBER: 336424396
VISIT DATE: 11/04/2021
NARRATIVE
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At the time of LPA Colvin's visit to the facility, Administrator Shaffer still retained the original positing, which was shown to LPA Colvin. R2 was not present when the posting was removed and did not give consent for Shaffer to remove the posting. LPA Colvin reviewed the positing and observed that it was addressed to R2 only, and therefore was communication and property belonging to R2, and not the facility. Therefore, based on interviews conducted, the allegation "Staff confiscated resident's personal property" is SUBSTANTIATED.

A finding that the complaint is SUBSTANTIATED means that the allegation(s) is valid because the preponderance of the evidence standard has been met.

Due to observations made by LPA Colvin, the facility was cited, and deficiency was noted on LIC 9099 D. An exit interview was conducted where this report and appeal rights were discussed. A copy this report, LIC 9099D, and appeal rights were provided to Executive Director/Administrator Ernie Shaffer during the exit interview.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Crystal ColvinTELEPHONE: (951) 204-0848
LICENSING EVALUATOR SIGNATURE:

DATE: 11/04/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Citations on this Visit Report are Under Appeal!

Control Number 18-AS-20211029114555
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: SEGOVIA OF PALM DESERT
FACILITY NUMBER: 336424396
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/04/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Under Appeal
Type A
11/05/2021
Section Cited
CCR
87468.2(a)(25)
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Additional Personal Rights of Residents in Privately Operated Facilities: (a) In addition to the rights listed...residents in privately operated residential care facilities...shall have all of the following personal rights: (25) To protection of their property from theft or loss... This requirement was not met by:
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Licensee agrees to review regulations regarding Additional Personal Rights of Residents (87468). Licensee to self-certify to LPA Colvin once completed and submit Statement of Understanding regarding facility's obligation to follow said regulations. Self-certification and Statement of Understanding
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Based on interviews and observations, the Licensee did not comply with the above regulation with one resident (R1). LPA Colvin found that Administrator Shaffer removed property of R1 (Cease and Desist letter) from R1's door. This was an immediate personal rights violation of R1.
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due by Plan of Correction date of 11/5/21.
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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: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Crystal ColvinTELEPHONE: (951) 204-0848
LICENSING EVALUATOR SIGNATURE:

DATE: 11/04/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 7
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
10/29/2021 and conducted by Evaluator Crystal Colvin
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20211029114555

FACILITY NAME:SEGOVIA OF PALM DESERTFACILITY NUMBER:
336424396
ADMINISTRATOR:ERNIE SHAFFERFACILITY TYPE:
741
ADDRESS:39905 VIA SCENATELEPHONE:
(760) 674-3200
CITY:PALM DESERTSTATE: CAZIP CODE:
92260
CAPACITY:182CENSUS: DATE:
11/04/2021
UNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Ernie Shaffer - Executive Director/AdministratorTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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9
Staff yelled at resident
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Crystal Colvin arrived at the facility unannounced in order to initiate an investigation of a complaint with the above allegation(s). LPA identified herself and discussed the purpose of the visit and the elements of the allegation(s) with Executive Director/Administrator Ernie Shaffer. Below is a summary of the complaint investigation findings:

Regarding allegation "Staff yelled at resident": LPA Colvin interviewed all persons present during the alleged incident. Interviews included resident(s) and staff who were in earshot of the location of the alleged incident. All persons present denied the allegation of staff yelling at the resident. All but one person interviewed confirmed that a conversation between Executive Director Ernie Shaffer and a resident took place in and/or around the lobby of the facility as well as one of the facility offices. Of those who recall the incident, all persons interviewed stated that Shaffer spoke in a "normal" conversational tone and volume at all times. Therefore, due to interviews conducted and lack of evidence, the allegation "Staff yelled at resident" is UNSUBSTANTIATED.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Crystal ColvinTELEPHONE: (951) 204-0848
LICENSING EVALUATOR SIGNATURE:

DATE: 11/04/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 7
Control Number 18-AS-20211029114555
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: SEGOVIA OF PALM DESERT
FACILITY NUMBER: 336424396
VISIT DATE: 11/04/2021
NARRATIVE
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A finding of UNSUBSTANTIATED means although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur.

An exit interview was conducted with Executive Director/Administrator Ernie Shaffer and a copy of this report was provided.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Crystal ColvinTELEPHONE: (951) 204-0848
LICENSING EVALUATOR SIGNATURE:

DATE: 11/04/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 7
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
10/29/2021 and conducted by Evaluator Crystal Colvin
COMPLAINT CONTROL NUMBER: 18-AS-20211029114555

FACILITY NAME:SEGOVIA OF PALM DESERTFACILITY NUMBER:
336424396
ADMINISTRATOR:ERNIE SHAFFERFACILITY TYPE:
741
ADDRESS:39905 VIA SCENATELEPHONE:
(760) 674-3200
CITY:PALM DESERTSTATE: CAZIP CODE:
92260
CAPACITY:182CENSUS: DATE:
11/04/2021
UNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Ernie Shaffer - Executive Director/AdministratorTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Staff locked resident in an office
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Crystal Colvin arrived at the facility unannounced in order to initiate an investigation of a complaint with the above allegation(s). LPA identified herself and discussed the purpose of the visit and the elements of the allegation(s) with Executive Director/Administrator Ernie Shaffer. Below is a summary of the complaint investigation findings:

Regarding allegation "Staff locked resident in an office": LPA Colvin conducted interviews with staff and residents present during the date and time of the alleged incident, and additionally toured the office in question. All persons LPA Colvin interviewed who were present during the alleged event reported that the resident (R1) was not locked in the room, and most report that the door of the room was kept open the entire time R1 was in said room. LPA Colvin additionally observed that the office that R1 was seated in during the alleged incident has a door handle which locks on both the inside and outside of the room. LPA Colvin tested the handle and confirmed that when engaging the lock, it can be both locked and unlocked by turning the mechanism on the handle on the inside of the room.
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Crystal ColvinTELEPHONE: (951) 204-0848
LICENSING EVALUATOR SIGNATURE:

DATE: 11/04/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 18-AS-20211029114555
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: SEGOVIA OF PALM DESERT
FACILITY NUMBER: 336424396
VISIT DATE: 11/04/2021
NARRATIVE
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Therefore, due to interviews conducted and observations made by LPA Colvin, the allegation "Staff locked resident in an office" is UNFOUNDED. 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. We have therefore dismissed the complaint.

An exit interview was conducted where this report was discussed. A copy of all reports and forms were provided to Executive Director/Administrator Ernie Shaffer during the exit interview.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Crystal ColvinTELEPHONE: (951) 204-0848
LICENSING EVALUATOR SIGNATURE:

DATE: 11/04/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2021
LIC9099 (FAS) - (06/04)
Page: 7 of 7