361800118-7-10-2020-18-AS-JESL-BSSVGG-20200824162530

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 361800118
Report Date: 07/10/2020
Date Signed: 07/10/2020 03:58:47 PM

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
05/28/2020 and conducted by Evaluator Javina George

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20200528141126

FACILITY NAME:	ANGELIC MANSIONS		FACILITY NUMBER:	361800118
ADMINISTRATOR:	RAJADAS, SHEILA		FACILITY TYPE:	740
ADDRESS:	7585 WARREN VISTA AVE		TELEPHONE:	(760) 365-4620
CITY:	YUCCA VALLEY	STATE: CA	ZIP CODE:	92284
CAPACITY:	15	CENSUS: 11	DATE:	07/10/2020
		UNANNOUNCED	TIME BEGAN:	03:15 PM
MET WITH:	Licensee-Phillip Rajadas		TIME COMPLETED:	03:50 PM

ALLEGATION(S):

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Staff did not adequately supervise resident resulting in multiple falls.

Staff did not provide adequate food service to residents.

Drinking water is not readily available to residents.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Javina George called the facility for the purpose of delivering findings for the above allegation(s) via telephone due to COVID-19. LPA George met with Licensee Phillip Rajadas and advised the purpose of visit. Below is a summary of the findings of the investigation:
The above complaint was investigated by the department. The investigation consisted of interviews of various individuals connected to the facility. As well as obtaining documentation that includes: a review of the facility's complaint history, SIRs, and staff overview conducted during shift change.
Based on a review of information gathered from documentation, and conducted interviews. LPA George was unable to corroborate the allegation(s). Per Licensee Steven Rajadas he is working at the facility as a live in caregiver to assist with providing increased supervision for all shifts.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Joel Esquivel	TELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javina George	TELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:	DATE: 07/09/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2020

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-20200528141126

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: ANGELIC MANSIONS	FACILITY NUMBER: 361800118
	VISIT DATE: 07/10/2020

NARRATIVE

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SIRs were reviewed and there were not any incidences that occurred due to lack of supervision. All residents have a call pendant to press when assistance is needed. The calls are recorded, and indicating the response time of staff.
The above allegation of Staff did not adequately supervise resident resulting in multiple falls is UNSUBSTANTIATED. A finding that the complaint is UNSUBSTANTIATED means 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. On 6/3/20 LPA George conducted an unannounced visit via Google Duo. LPA George was given a tour of the facility by Licensee's Phillip and Steven Rajadas. LPA George observed the pantry and refrigerator and freezer to be fully stocked. The facility had a 2 week supply of nonperishable food items and a 7 day supply of perishable food items. Feedback from residents indicated they are served good portions and offered seconds. The menu shows meals consists of 3 meals and LPA George observed containers of milk and a variety of juices for the residents. The above allegation of Staff did not provide adequate food service to residents is UNSUBSTANTIATED. A finding that the complaint is UNSUBSTANTIATED means 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.
During the visit on 6/3/20 LPA George observed that there was a small refrigerator located inside of the room adjacent to the kitchen, where LPA observed 3 one gallon bottles of Arrowhead spring water on the top shelf, and in the bottom drawer full with applesauce and pudding. There was a water filter connector at the top of the kitchen sink where licensee's explained that the water is fresh and each resident has a water bottle that is filled in the morning and in the evening, and in between if needed. LPA George observed that there were numerous blue jugs in the backyard of the facility and inquired as to what they were. Licensee Phillip explained that they jugs were full of water and was equivalent to 96 gallons of water, which can be used in the event of an emergency. The above allegation of Drinking water is not readily available to residents is UNSUBSTANTIATED. A finding that the complaint is UNSUBSTANTIATED means 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 and a copy of this report was provided to Licensee Phillip Rajadas via email.

SUPERVISOR'S NAME: Joel Esquivel	TELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javina George	TELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:	DATE: 07/09/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2020

LIC9099 (FAS) - (06/04)

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