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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 336426505
Report Date: 04/20/2023
Date Signed: 04/20/2023 09:20:48 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
04/12/2023 and conducted by Evaluator Javina George
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20230412172120
FACILITY NAME:STONEWALL GARDENS ASSISTED LIVINGFACILITY NUMBER:
336426505
ADMINISTRATOR:LAUREN KABAKOFFFACILITY TYPE:
740
ADDRESS:2150 N PALM CANYON DRTELEPHONE:
(760) 548-0970
CITY:PALM SPRINGSSTATE: CAZIP CODE:
92262
CAPACITY:35CENSUS: 17DATE:
04/20/2023
UNANNOUNCEDTIME BEGAN:
09:49 AM
MET WITH:Executive Director Lauren KabakookTIME COMPLETED:
03:35 PM
ALLEGATION(S):
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Facility does not have a current emergency disaster plan
Facility vehicle is in disrepair
Uncleared adults working at the facility.
Facility does not maintain accurate and complete resident and employee records/files.
Facility staff are not adequately trained.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA Javina George made an unannounced visit to the facility to commence a complaint investigation. LPA was greeted and granted entry by LVN/Assistant Executive Director Shannon Hundley. The Executive Director Lauren Kabakook arrived shortly after. LPA explained the purpose of the visit and the elements of the allegation(s) listed above. The allegation(s) were invesitgated. The investigation consisted of observation, interviews and record review.

Reagarding the allegation Facility does not have a current emergency disaster plan.
During a tour of the physical plant of the LPA observed in the hallway of the dining room for there to be an emergency disaster form (LIC610E) dated 4/1/22 and another inside the staff office dated 5/24/2022. It was evident that they are not updated as not only were there staff listed that are no longer working at the facility, in addition to the LIC form does not have the (03/19) date updated version, the facility has the (10/03) dated form. Based on observation and record review the allegation facility does not have a current emergency disaster plan is SUBSTANTIATED.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javina GeorgeTELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:

DATE: 04/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/20/2023
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 9
Control Number 18-AS-20230412172120
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: STONEWALL GARDENS ASSISTED LIVING
FACILITY NUMBER: 336426505
VISIT DATE: 04/20/2023
NARRATIVE
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Allegation: Facility vehicle is in disrepair LPA conducted a tour of the facility transportation van that was reportedly had recently removed seats to declare to state the van would be a ten-passenger van (1 driver and 9 passengers). LPA requested to review the inspections that have been conducted by California Highway Patrol. Lauren the Executive Director provided LPA with a copy of the chp343 titled Safety Compliance Report/terminal record update that was dated 2015 and indicated that the vehicle would be inactivate and defined as bus. Due to the capacity reduction in the van, annual inspections are not required. A further inspection of the van revealed that, the fire extinguisher was not secured and has the potential to roll around, there were also extra seat belts that were buckled from the seats that were removed and were found to be secured laying on the floor. There were some exposed wires Based on the facility vehicle is in disrepair is SUBSTANTIATED.

Allegation: Uncleared adults working at the facility. LPA conducted a review of the staff schedule, LIC 500 and compared it to the facility personnel report summary. LPA found there to be inaccuracies with the staff schedule and the LIC 500, as not all staff on the schedule were not indicated on the LIC 500. LPA observed for Staff #1 (S1) to be working at the at the facility, during LPA’s visit and is noted to have worked/been an employee since July 21, 2022, without having had obtained the proper clearance. S1 current status is "pending". As a result, LPA along with Executive Director Lauren and Assistant Executive Director Shannon escorted S1 off the community grounds, it was explained that they would be removed from the schedule until the proper clearance has been obtained. S1 stated that they were aware and was working on makingThe allegation of uncleared adults working in the facility is SUBSTANTIATED.

Allegation: Facility does not maintain accurate and complete resident and employee records/files. LPA conducted a review of seven (7) resident files of the 17 currently admitted to the facility. LPA observed for the resident files to have a completed physician’s report, preplacement appraisal, an assessment needs and services plan, emergency notification identification form, and Admissions agreement. LPA conducted a review of five (5) staff files according to the LIC500 there are a total of (15) staff. According to the table of contents the staff files are to include the training that the staff has received at initial employment and on going required training. LPA observed the following inconsistencies: 1 out of 5 staff files had a training checklist, 2 of the 5 staff records had a CPR/First Aid card showing that training had been received. 3 of the 5 staff files had a copy of the staff identification (DL, ID card). Based on record review the allegation of facility does not maintain accurate and complete resident and employee records/files is SUBSTANTIATED.

SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javina GeorgeTELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:

DATE: 04/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/20/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 9
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
04/12/2023 and conducted by Evaluator Javina George
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20230412172120

FACILITY NAME:STONEWALL GARDENS ASSISTED LIVINGFACILITY NUMBER:
336426505
ADMINISTRATOR:LAUREN KABAKOFFFACILITY TYPE:
740
ADDRESS:2150 N PALM CANYON DRTELEPHONE:
(760) 548-0970
CITY:PALM SPRINGSSTATE: CAZIP CODE:
92262
CAPACITY:35CENSUS: 17DATE:
04/20/2023
UNANNOUNCEDTIME BEGAN:
09:49 AM
MET WITH:Executive Director Lauren KabakookTIME COMPLETED:
03:35 PM
ALLEGATION(S):
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Facility does not properly store flammable liquids.
Administrator is not at the facility a sufficient amount of time
Facility is not maintained in a clean and sanitary condition.
Facility has excess trash.
Facility does not provide a safe environment for residents and staff.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA Javina George made an unannounced visit to the facility to commence a complaint investigation. LPA was greeted and granted entry by LVN/Assistant Executive Director Shannon Hundley. The Executive Director Lauren Kabakook arrived shortly after. LPA explained the purpose of the visit and the elements of the allegation(s) listed above. The allegation(s) were invesitgated. The investigation consisted of observation, interviews and record review.

Regarding the allegation of Facility does not properly store flammable liquids.
During a tour of the physical plant LPA observed for the facility to have a laundry that has a storage room. In the storage room there is emergency food, paper supplies such as paper towels and toilet paper. LPA observed there to be an air conditioning unit that had grab bars wrapped in plastic touching the unit. The unit was not in use and the Assistant Director moved the grab bars away at the time of LPAs visit. In addition, LPA observed for there to be boxes stacked as the same level of the sprinkler heads.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javina GeorgeTELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:

DATE: 04/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/20/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 9
Control Number 18-AS-20230412172120
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: STONEWALL GARDENS ASSISTED LIVING
FACILITY NUMBER: 336426505
VISIT DATE: 04/20/2023
NARRATIVE
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This too was corrected at the time of the visit, LPA did not observe any flammable liquids other than cleaning agents, that were properly stored, they were on a separate shelf away from the emergency food supply. The allegation of facility does not properly store flammable liquids is UNSUBSTANTIATED.

Administrator is not at the facility a sufficient amount of time

The facility does not keep a staff schedule indicating when administration would be on grounds. Per the LIC 500 the Administrator Lauren Kabakoff works at the facility Monday-Thursday 10am-7:00pm. Lauren is also on call 24/7. The facility has a second Administrator Shannon Hundley who works Monday-Friday 8am-5pm. Per interviews conducted Lauren is present on the days indicated, and the facility has an additional staff (Shannon) that holds the administrator certificate. Based on observation, interview and record review the allegation is UNSUBSTANTIATED.

Facility is not maintained in a clean and sanitary condition.

A tour of the physical plant was conducted, and the facility was observed to be clean, clutter and odor free. However, there were resident apartments (11, 16, 17, 24), that were observed to be cluttered and having piles of items such as shoes, papers, and drinking beverages etc. Per the Executive Director Lauren the facility policy is that the residents are encouraged to decorate how they would like and that it is acceptable as long as there is a free pathway to maneuver about the room for fire personnel and other visitors. LPA observed for the pathways to be clear, and free from obstruction. The stated apartments were not observed to be unsanitary or not clean, just had a lot of items placed stacked and or piled throughout the room. Based on observation and interviews the allegation is UNSUBSTANTIATED.

Facility has excess trash.

LPA conducted a tour of the physical plant and did not observe any excess trash. Per the Executive Director Lauren the dumpster is emptied 2-3 times a week on Mondays, Wednesdays and Fridays. The exterior of the physical plant was observed to be free of trash. The area where the dumpster sits in the back of the facility was clean, there were no stains, odors or lose flying trash observed. Based on observation and interviews the allegation facility has excess trash is UNSUBSTANTIATED.

SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javina GeorgeTELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:

DATE: 04/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/20/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 9
Control Number 18-AS-20230412172120
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: STONEWALL GARDENS ASSISTED LIVING
FACILITY NUMBER: 336426505
VISIT DATE: 04/20/2023
NARRATIVE
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Regarding the allegation of Facility does not provide a safe environment for residents and staff.

The facility offers 24/7 supervision, and is a secured perimeter, a code is required to get in and out of the gate/door. Each apartment has a pull cord in all restrooms and all residents are issued a pendant upon admission. The pendant can be worn around the resident's neck. The facility has a Licensed Vocational Nurse that is also on call 24/7. It was alleged that the volunteers do not provide a safe environment. Per Executive Director Lauren the facility does have a total of 10 volunteers. There are not any known instances where the volunteers have mistreated the residents when speaking to them, and socializing during happy hour, and other activities. In addition the residents and staff have not reported any concerns about how the volunteers and their conduct while on grounds. There are some volunteers that come 1 a week and some that come 2 times a month. There was not sufficient evidence to corroborate the allegation, therefore the allegation facility does not provide a safe environment for residents and staff is UNSUBSTANTIATED. A finding of UNSUBSTANTIATED means that 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 and a copy of this report was provided to Executive Director Lauren Kabakook.

SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javina GeorgeTELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:

DATE: 04/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/20/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 9
Control Number 18-AS-20230412172120
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: STONEWALL GARDENS ASSISTED LIVING
FACILITY NUMBER: 336426505
VISIT DATE: 04/20/2023
NARRATIVE
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Facility staff are not adequately trained.

LPA conducted a review of five (5) staff files according to the LIC500 there are a total of (15) staff. According to the table of contents the staff files a breakdown of training's are to be included in section 8, of the file. The training included would be that the staff has received at initial employment and on going required training LPA observed the following inconsistencies: 1 out of 5 staff files had a training checklist, 2 of the 5 staff records had a CPR/First Aid card showing that training had been received. 3 of the 5 staff files had a copy of the staff identification (DL, ID card). In addition staff #2 (S2)'s CPR/First Aid expired in February 2023. Based on record review the allegation of facility does not maintain accurate and complete resident and employee records/files is SUBSTANTIATED. A substantiated finding means that the preponderance of evidence standard has been met.

An exit interview was conducted and a copy of this report, 9099C, 9099D LIC 811, and appeal rights were provided to Executive Director Lauren Kabakook

SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javina GeorgeTELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:

DATE: 04/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/20/2023
LIC9099 (FAS) - (06/04)
Page: 9 of 9
Control Number 18-AS-20230412172120
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: STONEWALL GARDENS ASSISTED LIVING
FACILITY NUMBER: 336426505
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/20/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/05/2023
Section Cited
HSC
1569.17
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(c)(1)(A) Subsequent to initial licensure, a person specified in subdivision (b) who is not exempted from fingerprinting shall obtain either a criminal record clearance or an exemption, pursuant to subdivision (f) of this section or Section 1522.7, from the State Department of Social Services prior to employment, residence, or initial presence in a facility.This requirement is not met as evidenced by:
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The Licensee agrees to have S1 complete the process of obtaining an exemption. Proof of correction is to be submitted by 5pm on the due date indicated.
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Based on observations, interviews and records review, the Licensee did not comply with the section cited above on 1 out 1 time, as S1 began working without having a fingerprint clearance. This poses an immediate health, saftey and personal rigths risk to persons in care.
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Type A
04/21/2023
Section Cited
CCR
87468.1(a)(2)
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RCFEs shall have all of the following personal rights: To be accorded safe, healthful & comfortable accommodations, furnishings and equipment. This requirement was not met as evidenced by: The facility van fire extinguisher is not mounted and can roll around the van.
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The licensee agrees to have the fire extinguisher mounted in a safe location inside the van will be completed next Wednesday by Aizen fire protection on 4/26/23 at 8:30am, to have it remounted.
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This poses an immediate health, safety and personal rights risks to persons 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: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javina GeorgeTELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:

DATE: 04/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/20/2023
LIC9099 (FAS) - (06/04)
Page: 6 of 9
Control Number 18-AS-20230412172120
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: STONEWALL GARDENS ASSISTED LIVING
FACILITY NUMBER: 336426505
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/20/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/04/2023
Section Cited
CCR
87565(c)
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Personnel requirements-general-All RCFE staff are to have 10 hours of initial training in their first 4 weeks of employment and at least 4 hours of training annually thereafter. This requirement is not met as evidenced by:
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The licensee agrees to provide the training transcripts for the 5 out of 5 staff files indentified on the LIC 811 by 5 pm on the due date indicated.
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5 out of 5 facility staff did not find any documentation of training provided to any staff of 5 files that were reviewed. This poses an immediate health, safety and personal rights risk to persons in care.
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Type B
05/04/2023
Section Cited
CCR
87412(a)(1)
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PERSONNEL RECORDS
The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information. LPA observed staff files not to be complete, information
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Licensee is to ensure all staff files are maintained with staff training information.

Licensee is to submit proof of correction to CCL by the due date
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missing. records verification of required staff training and orientation, as specified.
Documentation of staff training shall include(A) Trainer's full name; (B) Subject(s) covered
This poses a potential health, safety, personal rights risk to persons 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: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javina GeorgeTELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:

DATE: 04/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/20/2023
LIC9099 (FAS) - (06/04)
Page: 8 of 9
Control Number 18-AS-20230412172120
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: STONEWALL GARDENS ASSISTED LIVING
FACILITY NUMBER: 336426505
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/20/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/21/2023
Section Cited
CCR
87208
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87208 Plan of Operation
(a) Each facility shall have and maintain a current, written definitive plan of operation. The plan and related materials shall be on file in the facility and shall be submitted to the licensing agency with the license application. Any significant changes in the plan of operation which would affect the services to residents shall be submitted to the licensing agency for approval. The plan and related materials shall contain the following:
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The Licensee agrees to update the facility's emergency diaster plan. Proof is to be submitted by 5pm on the due date indicated.
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This requirement is not med as evidenced by the LIC610E was not on the updated form and there were staff with designated duties. This poses an immediate health, safety and personal rights risk to persons 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: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javina GeorgeTELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:

DATE: 04/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/20/2023
LIC9099 (FAS) - (06/04)
Page: 7 of 9