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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 336426289
Report Date: 06/06/2022
Date Signed: 06/06/2022 10:58:40 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
06/01/2022 and conducted by Evaluator Crystal Colvin
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20220601130721
FACILITY NAME:CRYSTAL SPRINGS SENIOR CARE FACILITYFACILITY NUMBER:
336426289
ADMINISTRATOR:NUNEZ, NELLYFACILITY TYPE:
740
ADDRESS:41747 WHITTIER AVENUETELEPHONE:
(951) 658-4817
CITY:HEMETSTATE: CAZIP CODE:
92544
CAPACITY:6CENSUS: 6DATE:
06/06/2022
UNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Nelly Nunez - Licensee/AdministratorTIME COMPLETED:
11:00 AM
ALLEGATION(S):
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Staff did not address a resident's change in medical condition

Staff is denying visitations for a resident while in care
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 Licensee/Administrator Nelly Nunez. Below is a summary of the findings of this complaint:

Regarding allegation "Staff did not address a resident's change in medical condition": LPA Colvin reviewed resident's (R1) facility file, text messages between Licensee/Administrator Nunez and R1's Power of Attorney (POA) and conducted interviews. LPA Colvin observed that R1 has a designated POA for healthcare decisions and is additionally on Hospice. Interviews revealed that when staff observed signs of possible stroke in R1, they immediately communicated with R1's POA to inquire if they wanted R1 to be sent to the hospital or evaluated by Hospice. Through review of text messages, LPA Colvin confirmed that facility staff have been in communication with R1's POA regarding medical care since the possible stroke and have been following R1's POA's wishes. Therefore, due to record review and interviews, the allegation "Staff did not address a resident's
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Crystal Colvin
LICENSING EVALUATOR SIGNATURE:

DATE: 06/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/06/2022
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 2
Control Number 18-AS-20220601130721
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: CRYSTAL SPRINGS SENIOR CARE FACILITY
FACILITY NUMBER: 336426289
VISIT DATE: 06/06/2022
NARRATIVE
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change in medical condition" is UNFOUNDED.

Regarding allegation "Staff is denying visitations for a resident while in care": LPA Colvin conducted interviews and reviewed the facility's record for visitor sign-in, LPA Colvin observed a sign posted on the outside of the front of the facility stating that appointments need to be made for visitation. LPA Colvin inquired about this with the Licensee/Administrator, who stated that this was due to infection control concerns with COVID-19, but that they do not deny visitors without an appointment, nor do they restrict appointments overlapping in time (they will just advise the visitors of the overlapping appointments, so they can be informed). LPA Colvin conducted interviews with a sample of the residents, the Licensee/Administrator, and other interested parties, and all statements confirm that they have never had a visitor turned away or they themselves be turned away from visiting. Review of the facility's visitor log shows visits to residents every day from numerous persons. Therefore, due to record review and interviews, the allegation "Staff is denying visitations for a resident while in care" 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 Licensee/Administrator Nelly Nunez during the exit interview.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Crystal Colvin
LICENSING EVALUATOR SIGNATURE:

DATE: 06/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/06/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2