361800187-12-7-2022-18-AS-NBRN-CMJUBH-20221228142618

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 361800187
Report Date: 11/23/2022
Date Signed: 12/07/2022 11:51:30 AM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 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
10/06/2020 and conducted by Evaluator Amber Coleman

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20201006151422

FACILITY NAME:	ROSE VALLEY REDLANDS		FACILITY NUMBER:	361800187
ADMINISTRATOR:	LEE, PATRICK C		FACILITY TYPE:	740
ADDRESS:	153 S DEARBORN ST		TELEPHONE:	(909) 389-7586
CITY:	REDLANDS	STATE: CA	ZIP CODE:	92374
CAPACITY:	6	CENSUS: 6	DATE:	11/23/2022
		UNANNOUNCED	TIME BEGAN:	08:56 AM
MET WITH:	Delfina Villamore		TIME COMPLETED:	03:15 PM

ALLEGATION(S):

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7
8
9

1. Staff are mismanaging medication.
2. Staff are not properly trained

INVESTIGATION FINDINGS:

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13

Licensing Program Analysts Amber Coleman and Anna Bueno (LPA) arrived at the Rose Valley Facility to make an unannounced visit to initiate a complaint investigation. LPA’s were greeted and invited inside by staff member Delfina Villamore. LPA’s introduced self and stated purpose of the visit.

LPA's conducted staff and resident interviews, records review, and pill count during the visit.

It is alleged that staff are not properly trained and that the medication is being mismanaged. During the records review, LPA reviewed 6 resident Medication Administration Records (MARS) of 6 resident records, 4 records displayed that medications dispensed were not signed for. Dates November 12th through November 23rd were missing signatures. While conducting staff interview regarding missing signatures. S1 explained, "Sometimes they forget to sign, but the medication is given. I will remind them to sign." Pill count for R1 displayed that routine medications were dispensed appropriately.

Review of personnel files revealed training materials were present, however there was no evidence that training was completed by staff members.

We have substantiated the complaint allegation(s) as valid and that a violation has occurred based on the preponderance of available evidence. A copy of this report along with appeal rights are being reviewed with, and furnished to the facility representative. Please see LIC 9099D. A copy of this report along with appeal rights are being reviewed with and furnished to the facility representative.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Amber Coleman	TELEPHONE: 951-248-0338
LICENSING EVALUATOR SIGNATURE:	DATE: 11/23/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/23/2022

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-20201006151422

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: ROSE VALLEY REDLANDS	FACILITY NUMBER: 361800187
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/23/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 11/23/2022 Section Cited CCR 87411(C)	1 2 3 4 5 6 7	All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69	1 2 3 4 5 6 7	Administrator agreed to have a Hospice Agency come to the facility to provide medication training to staff members who work directly with residents with in the next 3 weeks. Administrator agreed to have medication training with hospice agency scheduled Administrator also agrees to move forward with in house training by January 2023.
	8 9 10 11 12 13 14	This requirement was not met as evidenced by the lack of record or proof of completion of medication training could not be provided.	8 9 10 11 12 13 14
CCR	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	8 9 10 11 12 13 14		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: Amber Coleman	TELEPHONE: 951-248-0338
LICENSING EVALUATOR SIGNATURE:	DATE: 11/23/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/23/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 3

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 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
10/06/2020 and conducted by Evaluator Amber Coleman

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20201006151422

FACILITY NAME:	ROSE VALLEY REDLANDS		FACILITY NUMBER:	361800187
ADMINISTRATOR:	LEE, PATRICK C		FACILITY TYPE:	740
ADDRESS:	153 S DEARBORN ST		TELEPHONE:	(909) 389-7586
CITY:	REDLANDS	STATE: CA	ZIP CODE:	92374
CAPACITY:	6	CENSUS: 6	DATE:	11/23/2022
		UNANNOUNCED	TIME BEGAN:	08:56 AM
MET WITH:	Delfina Villamore		TIME COMPLETED:	03:15 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

1. Staff handle residents roughly.
2. Staff do not ensure residents hygiene needs are met.
3. Administrator is not at facility for the required hours.
4. Residents are not being fed.

INVESTIGATION FINDINGS:

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

Licensing Program Analysts Amber Coleman and Anna Bueno (LPA) arrived at the Rose Valley Facility to make an unannounced visit to initiate a complaint investigation. LPA’s were greeted and invited inside by staff member Delfina Villamore. LPA’s introduced self and stated purpose of the visit.

LPA's conducted interviews with both staff and residents and a walk through the facility.

It is alleged that the residents are being handled roughly. All residents interviwed denied that staff have touched them inappropriately or violently during their time spent residing in the facility. LPA did not observe any inexlicable marks are bruising on residents or witness any warning signs of abuse during interviews.

It is alleged that staff do not ensure resident's hygeiene needs are being met. LPA walked through facility's bathrooms. All bathrooms were in functioning condition. LPA observed residents to be well groomed free of body odor. Residents reported to have the assistance with their activities of daily living.

Staff interview revealed that the Adminstrator is present at facility for a sufficient amount of hours during the day. In the event the Administrator is not available, adequate staff is available to step in and provide direction.

It is alleged that the residents are not being fed. LPA's observed staff members cooking lunch during the visit. A walkthrough of the facility revealed there is adequate food available for the residents in care. Additionally, residents deny that they were not provided enough food during meals.

We have found the complaint allegation is unsubstantiated, although the allegation may have happened or is valid: there is not a preponderance of the evidence to prove that the alleged violation occurred. A copy of this report is being reviewed with and furnished to the facility representative.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Amber Coleman	TELEPHONE: 951-248-0338
LICENSING EVALUATOR SIGNATURE:	DATE: 11/23/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/23/2022

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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