361880611-9-29-2021-18-AS-JESL-C7BSF3-20210929134938

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 361880611
Report Date: 09/29/2021
Date Signed: 09/29/2021 10:45:26 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
08/05/2020 and conducted by Evaluator Crystal Colvin

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20200805090448

FACILITY NAME:	LA FUENTE LAVENDER 4		FACILITY NUMBER:	361880611
ADMINISTRATOR:	MELINDA HILARIO		FACILITY TYPE:	740
ADDRESS:	1155 N GLENWOOD AVE		TELEPHONE:	(909) 258-2085
CITY:	RIALTO	STATE: CA	ZIP CODE:	92376
CAPACITY:	0	CENSUS: 0	DATE:	09/29/2021
		UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Chandler Ramas - Licensee		TIME COMPLETED:	11:00 AM

ALLEGATION(S):

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Resident sustained injuries while in care due to neglect/lack of supervision

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Crystal Colvin held an office meeting with Licensee Chandler Ramas to deliver findings of the complaint with the above allegation. Below is a summary of the findings of the investigation:

Regarding allegation "Resident sustained injuries while in care due to neglect/lack of supervision": An investigation was conducted by the Department which included interviews and review of relevant records from the facility and from Arrowhead Regional Medical Center (ARMC). During the investigation it was discovered that Resident #1 (R1) had sustained a fall at the facility on July 28, 2020, in which medical attention was not sought despite reports that R1 had sustained bruises to the face and suffered from nosebleed due to the fall. Additionally, on August 4, 2020, 911 was called by staff and R1 was taken to ARMC due to reports of R1 being combative. When R1 was assessed at the hospital, it was discovered that R1 had a 7-centimeter laceration to the left forearm and a 2-centimeter healing laceration above left eye.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Joel Esquivel	TELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Crystal Colvin	TELEPHONE: (951) 204-0848
LICENSING EVALUATOR SIGNATURE:	DATE: 09/29/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2021

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-20200805090448

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: LA FUENTE LAVENDER 4	FACILITY NUMBER: 361880611
	VISIT DATE: 09/29/2021

NARRATIVE

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Facility staff claimed no knowledge of injuries to R1. Therefore, due to interviews and record review, the allegation is SUBSTANTIATED. A finding that the complaint is SUBSTANTIATED means that the allegation(s) is valid because the preponderance of the evidence standard has been met.

Due to findings of the investigation, the facility was cited, and deficiencies noted on LIC 9099D. An exit interview was conducted where this report, and appeal rights were discussed. A copy of all reports, forms, and appeal rights were provided to Licensee Chandler Ramas during the exit interview.

SUPERVISOR'S NAME: Joel Esquivel	TELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Crystal Colvin	TELEPHONE: (951) 204-0848
LICENSING EVALUATOR SIGNATURE:	DATE: 09/29/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2021

LIC9099 (FAS) - (06/04)

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Control Number 18-AS-20200805090448

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: LA FUENTE LAVENDER 4	FACILITY NUMBER: 361880611
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/29/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 10/01/2021 Section Cited HSC 1569.269(a)(6)	1 2 3 4 5 6 7	Enumerated Rights; severability: Residents... shall have.. following rights: To care, supervision, and services that meet their individual needs and are delivered by staff that are ...competency to meet their needs. This requirement was not met by:	1 2 3 4 5 6 7	Licensee states that he will have staff at his other licensed facilties re-trained on conducting regular body checks of residents as well as ensuring they know what injuries to report and call 911 for. Additionally staff will be trained to document any observations. Licensee to submit proof of training to LPA by Plan of
	8 9 10 11 12 13 14	Based on interviews and record review, the Licensee did not comply with the above regulation; R1 was not provided medical attention on 7/28/20 and was admitted to the hospital on 8/4/20 with 2 cuts (eft forearm & above left eye). Facility staff claimed no knowledge of cuts. This was an immediate safety risk.	8 9 10 11 12 13 14	Correction date of 10/1/21. Extension to be granted to Licensee to 10/14/21 due to number of staff/facilties to train as well as other corrections to be made for other complaints.
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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 Esquivel	TELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Crystal Colvin	TELEPHONE: (951) 204-0848
LICENSING EVALUATOR SIGNATURE:	DATE: 09/29/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2021

LIC9099 (FAS) - (06/04)

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