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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 336425030
Report Date: 08/28/2024
Date Signed: 08/28/2024 12:26:33 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
02/07/2020 and conducted by Evaluator Javier Prieto
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20200207105543
FACILITY NAME:AVATAR RETIREMENT HOMEFACILITY NUMBER:
336425030
ADMINISTRATOR:JAMAL ALKAWASSFACILITY TYPE:
740
ADDRESS:44645 SAN ONOFRE AVENUETELEPHONE:
(760) 340-5191
CITY:PALM DESERTSTATE: CAZIP CODE:
92260
CAPACITY:10CENSUS: 8DATE:
08/28/2024
UNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Angel Sanchez, House ManagerTIME COMPLETED:
12:40 PM
ALLEGATION(S):
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Facility failed to keep resident adequately hydrated
INVESTIGATION FINDINGS:
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LPA Javier Prieto and LPA Eldin Serrano arrived at the facility to delivery findings to the listed allegations. LPA met with house manager Angel Sanchez and explained the nature of the visit.
The investigation, conducted by Department staff consisted of interviews with relevant parties, and file reviews revealed that the administrator called 911 due to Resident 1 (R1) having a fast heart rate. R1 was admitted to the hospital on 2/4/2020, and discharged back to the facility on 2/6/2020, on hospice. Hospital documents indicates that R1 was dehydrated.

Based on the LPAs interviews, and review of documents the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. An exit interview was conducted where this report, LIC 9099D, and appeal rights were discussed with and provided to the house manager.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: 9512480349(323) 981-3968
LICENSING EVALUATOR NAME: Javier PrietoTELEPHONE: 951-217-3135
LICENSING EVALUATOR SIGNATURE:

DATE: 08/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2024
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-20200207105543
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: AVATAR RETIREMENT HOME
FACILITY NUMBER: 336425030
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/28/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/03/2024
Section Cited
CCR
87705(c)(3)(A)
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CARE OF PERSONS WITH DEMENTIA Licensees who accept residents with dementia shall be responsible for ensuring:(3)on-the-job training to staff who provide direct care.(A) which should include, but not limited to, knowledge about hydration.
This requirement was not met as evidenced by:
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The facility will ensure that all residents are properly hydrated and assessed for signs of dehydration. A declaration will be sent to LPA by the POC date,
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Based on interviews and record review, the facility failed to ensure that Resident 1 (R1) remained hydrated. Hospital discharge documents dated 2/6/20 indicates R1 was dehydrated.

This poses an immediate health and safety risk to residents in care.
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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: Karen ClemonsTELEPHONE: 9512480349(323) 981-3968
LICENSING EVALUATOR NAME: Javier PrietoTELEPHONE: 951-217-3135
LICENSING EVALUATOR SIGNATURE:

DATE: 08/28/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
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
02/07/2020 and conducted by Evaluator Javier Prieto
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20200207105543

FACILITY NAME:AVATAR RETIREMENT HOMEFACILITY NUMBER:
336425030
ADMINISTRATOR:JAMAL ALKAWASSFACILITY TYPE:
740
ADDRESS:44645 SAN ONOFRE AVENUETELEPHONE:
(760) 340-5191
CITY:PALM DESERTSTATE: CAZIP CODE:
92260
CAPACITY:10CENSUS: 8DATE:
08/28/2024
UNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Angel Sanchez, House ManagerTIME COMPLETED:
12:40 PM
ALLEGATION(S):
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9
Resident sustained an unexplained bruise while in care
Resident sustained pressure injuries while in care
INVESTIGATION FINDINGS:
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On 08/28/2024 Licensing Program Analyst (LPA) Javier Prieto and LPA Eldin Serrano conducted an unannounced visit for the purpose of delivering the findings to the above allegations. LPA met with House Manager Angel Sanchez, explained the nature of the visit and was granted entry.

The investigation, which consisted of interviews and document review revealed the following:
Allegation #1 Resident sustained a unexplained bruise while in care: Resident 1 (R1) slept in a hospice bed with rails, rolled over and hit the eyebrow area, which led to a small bruise. R1's son was notified of the accident. R1's son confirmed knowledge of the incident. Allegation #2 Resident sustained pressure injuries while in care: An interview with staff revealed that pressure injuries were not observed on R1 prior to the R1 leaving for the Emergency Department (ED) on 2/4/20. Upon return to the facility on 2/6/20, R1 pressure injuries were not observed. The discharge documents sent home with R1 did not indicate that R1 had pressure injuries. 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, therefore the allegation is UNSUBSTANTIATED at this time. An exit interview was conducted where this report was discussed with and provided to the House Manager.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: 9512480349(323) 981-3968
LICENSING EVALUATOR NAME: Javier PrietoTELEPHONE: 951-217-3135
LICENSING EVALUATOR SIGNATURE:

DATE: 08/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 3