336426708-12-8-2021-18-AS-EMAN-C9SRVR-20211217122154

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 336426708
Report Date: 12/08/2021
Date Signed: 12/08/2021 11:39:19 AM

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
06/03/2020 and conducted by Evaluator Jennifer Semin

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20200603151825

FACILITY NAME:	ABOUNDING LOVE HOME CARE		FACILITY NUMBER:	336426708
ADMINISTRATOR:	DELA CRUZ, DENNIS		FACILITY TYPE:	740
ADDRESS:	13213 NAPA VALLEY COURT		TELEPHONE:	(951) 961-1303
CITY:	MORENO VALLEY	STATE: CA	ZIP CODE:	92555
CAPACITY:	6	CENSUS: 5	DATE:	12/08/2021
		UNANNOUNCED	TIME BEGAN:	08:28 AM
MET WITH:	Caregiver Sonia De La Cruz		TIME COMPLETED:	11:55 AM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Lack of supervision resulting in resident wandering from the facility
Facility staff failed to ensure resident was receiving medical treatments

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Progran Analyst (LPA) Jennifer Semin conducted an unannounced visit to deliver the findings for the above compalint allegations. LPA mer with Sonia De La Cruz.
The investigation consisted of interviews with staff, resident and relevant parties. Regarding the first allegation, Lack of supervision resulting in resident wandering from the facility. Facility staff stated Resident 1 (R1) is independent and able to leave the facility unassisted. R1 stated R1 is independent and leaves the facility to visit with friends and go shopping. Relevant parties stated R1 is independent to leave the facility unassisted.
The second allegation, Facility staff failed to ensure resident was receiving medical treatments. Facility staff, Resident 1 (R1) and relevant parties stated all R1’s appointments and transportation are completed by an outside agency.
Based upon interviews and information gathered, and although the allegation may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegations are UNSUBSTANTIATED at this time.
An exit interview was conducted where this report was discussed and provided to Ms. De La Cruz.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 836-2784
LICENSING EVALUATOR NAME: Jennifer Semin	TELEPHONE: (951) 473-7024
LICENSING EVALUATOR SIGNATURE:	DATE: 12/08/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/08/2021

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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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
06/03/2020 and conducted by Evaluator Jennifer Semin

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20200603151825

FACILITY NAME:	ABOUNDING LOVE HOME CARE		FACILITY NUMBER:	336426708
ADMINISTRATOR:	DELA CRUZ, DENNIS		FACILITY TYPE:	740
ADDRESS:	13213 NAPA VALLEY COURT		TELEPHONE:	(951) 961-1303
CITY:	MORENO VALLEY	STATE: CA	ZIP CODE:	92555
CAPACITY:	6	CENSUS: 5	DATE:	12/08/2021
		UNANNOUNCED	TIME BEGAN:	08:28 AM
MET WITH:	Caergiver-Sonia De La Cruz		TIME COMPLETED:	11:55 AM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility staff failed to report resident missing

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Progran Analyst (LPA) Jennifer Semin conducted an unannounced visit to deliver the findings for the above compalint allegations. LPA mer with Sonia De La Cruz

The investigation consisted of interviews with staff, resident and relevant parties. Regarding the allegation, Facility staff failed to report resident missing. Facility staff admitted to not filing a missing persons report for the incident in question when the resident did not return to the facility.

Based on interviews, which were conducted, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6 & Chapter 1) is being cited on the attached LIC9099D.

An exit interview was conducted where this report, LIC9099D, and appeal rights were discussed and provided to Ms. De La Cruz.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 836-2784
LICENSING EVALUATOR NAME: Jennifer Semin	TELEPHONE: (951) 473-7024
LICENSING EVALUATOR SIGNATURE:	DATE: 12/08/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/08/2021

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 3

Control Number 18-AS-20200603151825

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: ABOUNDING LOVE HOME CARE	FACILITY NUMBER: 336426708
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/08/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 12/09/2021 Section Cited CCR 87211(a)(2)	1 2 3 4 5 6 7	Reporting Requirements. Occurrences, which threaten the welfare, safety or health of residents, personnel or visitors, shall be reported within 24 hours either by telephone or facsimile to the licensing agency and to the person responsible for the resident. On 5/31/2020 Resident #1 left the facility and	1 2 3 4 5 6 7	Licensee shall immediately review and train all staff on Section 87211 Reporting Requirements and develop a plan so that this type of incident does not happen again. The plan and proof of training shall be provided to CCLD by the POC date of 12/9/2021.
	8 9 10 11 12 13 14	did not return and law enforcement was not immediately made aware of the incident.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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 Clemons	TELEPHONE: (951) 836-2784
LICENSING EVALUATOR NAME: Jennifer Semin	TELEPHONE: (951) 473-7024
LICENSING EVALUATOR SIGNATURE:	DATE: 12/08/2021

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/08/2021

LIC9099 (FAS) - (06/04)

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