336426746-11-8-2021-18-AS-NBRN-C8PU2E-20211112141148

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 336426746
Report Date: 11/08/2021
Date Signed: 11/08/2021 10:33:17 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 MS29-26
RIVERSIDE, CA 92507

This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/07/2021 and conducted by Evaluator Shaunte Henry

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20210107155833

FACILITY NAME:	PETUNIA ROYALE ASSISTED LIVING, LLC		FACILITY NUMBER:	336426746
ADMINISTRATOR:	FELICITAS MABBAYAD		FACILITY TYPE:	740
ADDRESS:	74127 E. PETUNIA PLACE		TELEPHONE:	(760) 779-5898
CITY:	PALM DESERT	STATE: CA	ZIP CODE:	92211
CAPACITY:	6	CENSUS: 4	DATE:	11/08/2021
		UNANNOUNCED	TIME BEGAN:	10:15 AM
MET WITH:	Floreline Esteban		TIME COMPLETED:	10:45 AM

ALLEGATION(S):

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Resident was inappropriately restrained while in care
Facility does not have hot water

INVESTIGATION FINDINGS:

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On 11/8/21 Licensing Program Analyst (LPA) Shaunte Henry conducted an unannouced visit for the purpose of delivering the findings to the above allegations. LPA Henry met with Floreline Esteban, explained the purpose of the visit and was granted entry into the facility.

The investigation, which consisted of interviews and document review, revealed the following:
Resident was inappropriately restrained while in care :
The hospice nurse of Resident 1 (R1) stated they visited R1 on 1/12/21 and the bedside table was positioned over R1's legs, which left R1 restrained.
***Continued on LIC 9099C***

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Edna Musoke	TELEPHONE: (951) 248-0336
LICENSING EVALUATOR NAME: Shaunte Henry	TELEPHONE: (951) 217-0236
LICENSING EVALUATOR SIGNATURE:	DATE: 11/08/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2021

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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Control Number 18-AS-20210107155833

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: PETUNIA ROYALE ASSISTED LIVING, LLC	FACILITY NUMBER: 336426746
	VISIT DATE: 11/08/2021

NARRATIVE

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***Continued from LIC 9099***

R1's arms were resting on top of the table. The table was lowered all the way down on top of R1's legs and the table could not be moved. The table was positioned by Staff 1 (S1)The administrator stated that he was only notified of one incident that occurred on 1/8/21. The administrator provided additional abuse training to S1 on 1/8/21. S1 left their position at the facility on 3/1/21. Based on interviews conducted, this allegation is substantiated.

Facility does not have hot water:
On 1/7/21 and 1/8/21, R1's hospice aide visited the facility and observed that the facility did not have hot water. The hospice aide checked both bathrooms and was not able to produce hot water. R1's social worker accompanied the hospice aide on a visit to the facility on 1/8/21 and confirmed that there was no hot water in the facility. The administrator stated he installed a digital tankless water heater to correct the issue.

Based on the LPA's observations and interviews, which were conducted, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6) is being cited on the attached LIC9099D.

During the visit on 11/8/21, LPA Henry was able to confirm that the facility has hot water.

An exit interview was conducted where this report, LIC 9099D, LIC 811 and appeal rights were provided to Floreline Esteban.

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Shaunte Henry	TELEPHONE: (951) 217-0236
LICENSING EVALUATOR SIGNATURE:	DATE: 11/08/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2021

LIC9099 (FAS) - (06/04)

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Control Number 18-AS-20210107155833

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: PETUNIA ROYALE ASSISTED LIVING, LLC	FACILITY NUMBER: 336426746
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/08/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 11/08/2021 Section Cited CCR 87468.1	1 2 3 4 5 6 7	Personal Rights of Residents: Residents...shall...be free from punishment, humiliation, intimidation, abuse... This requirement was not met as evidenced by:	1 2 3 4 5 6 7	The facility will provide elder abuse training to staff and provide proof to the department by the POC date.
	8 9 10 11 12 13 14	Based of interviews and record review, On 1/12/21 Staff 1(S1) placed Resident 1(R1)'s bedside table over R1's legs as a restraint. This is an immediate health and safety risk to residents in care.	8 9 10 11 12 13 14
Type A 11/08/2021 Section Cited CCR 87303(a)	1 2 3 4 5 6 7	Maintenance and Operation.The facility shall be clean, safe, sanitary and in good repair at all times. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	The facility will ensure the maintenance of the hot water system. The facility will provide proof of correction to the department by the POC date.
	8 9 10 11 12 13 14	Based on interviews and record review, the facility failed to maintain hot water on 17/21 and 1/8/21. The	8 9 10 11 12 13 14

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: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Shaunte Henry	TELEPHONE: (951) 217-0236
LICENSING EVALUATOR SIGNATURE:	DATE: 11/08/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2021

LIC9099 (FAS) - (06/04)

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