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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 361880611
Report Date: 09/29/2021
Date Signed: 09/29/2021 10:32:25 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
10/31/2019 and conducted by Evaluator Javina George
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20191031134929
FACILITY NAME:LA FUENTE LAVENDER 4FACILITY NUMBER:
361880611
ADMINISTRATOR:MELINDA HILARIOFACILITY TYPE:
740
ADDRESS:1155 N GLENWOOD AVETELEPHONE:
(909) 421-2561
CITY:RIALTOSTATE: CAZIP CODE:
92376
CAPACITY:0CENSUS: 0DATE:
09/29/2021
ANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Licensee Sotero Chandler RamasTIME COMPLETED:
10:30 AM
ALLEGATION(S):
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Facility staff is forcing resident to sign benefit documents
Staff are not providing medication as prescribed
Staff yells at resident while in care
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Javina George met with Licensee at the Regional Office for the purpose of delivering findings for the above allegation(s) LPA George met Sotero Chandler Ramas and advised the purpose of visit. The above complaint was investigated by the department.

Allegation: Facility staff is forcing resident to sign benefit documents

Based on review of documentation, and interviews conducted. Interviews established that Resident #1 (R1) was instructed in October 2019, by Staff #1 (S1) to sign legal documents stating that R1 had seen a Doctor. S1 instructed R1 to sign documents with doctor’s orders and signature to establish benefits. It was further noted that if R1 did not sign legal documents.
Additionally, it was established that R1 had not seen a Doctor as indicated. Based on the preponderance of evidence, the allegation; Facility staff is forcing resident to sign benefit documents is SUBSTANTIATED.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javina GeorgeTELEPHONE: (951) 204-7107
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)
Page: 1 of 6
Control Number 18-AS-20191031134929
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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Allegation- Staff failed to dispense medication as prescribed by physician.
The above complaint was investigated by the department. Based on review of documentation, and interviews conducted. Resident #1 (R1), Medication Administration Records sheets (MARs) were reviewed from September, October and November 2019. MAR sheets revealed that (R1) medication was not being given as prescribed by physician. MAR sheet for September 2019 showed that R1 was not given medication (Potassium CL) for 11 days in a row. MAR sheets showed that in October 2019 R1 was not given medications (Potassium CL, Digestion 360 with magnesium) for four days in a row. In addition, in November 2019, R1 was not given (Losartan, Sulfamethoxazole, Hydralazine, Vitamin C supplement, Vitamin D3 supplement) up to two days in a row. Based on the preponderance of evidence, the allegation; Staff failed to dispense medication as prescribed by physician is thereby SUBSTANTIATED.

Allegation- Staff yells at resident while in care.
The above complaint was investigated by the department. Based on review of documentation, and interviews conducted; it was established that one staff, Staff #1 (S1) was overheard yelling at residents. Interviews conducted also depicted staff yelling at residents when questions or concerns were brought to S1's attention. Concerns such as the loud noise that one of the resident’s beds would make, when the remote is used. The frequency of the amount of times that this occurred is unknown. Based on the information provided the allegation of Staff yells at resident while in care is found to be SUBSTANTIATED. A finding that the complaint is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met.

Based on the investigation findings noted above deficiencies were cited according to California Code of Regulations (Title 22, Division 6, chapter 8).

An exit interview was conducted and a copy of this report, 9099D and appeal rights were provided to Licensee Sotero Chandler Ramas.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javina GeorgeTELEPHONE: (951) 204-7107
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)
Page: 2 of 6
Control Number 18-AS-20191031134929
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
CCR
87465(a)(5)
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 87465(a)(5) Incidental Medical and Dental Care
87465(a)(5) - A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: The licensee shall assist residents with self-administered medications as needed.

Based on observation, interview and record review, this requirement was not met as evidenced by: The licensee did not ensure did not ensure that medications were given as prescribed on at least 11 out of 11 times. This poses an immediate health, safety or personal rights risk to persons in care.
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The Licensee agrees to conduct a staff in service on medication administration. Proof is to be submitted to the department by 5pm on the due date indicated.
Type B
10/14/2021
Section Cited
CCR
87207
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87207 False Claims No licensee,
officer or employee of a licensee shall make or disseminate any false or misleading statement regarding the facility or any of the services provided by the facility.

Based on observation, interview and record review, this requirement was not met as evidenced by: The licensee did not ensure that there were any misleading statements made regarding R1 on 1 out of 1 time. This poses a potential health, safety or personal rights risk to persons in care.
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The Licensee agrees to conduct an in service on documentation. Proof is to be submitted to the department by 5pm on the due date indicated.
Type B
10/14/2021
Section Cited
CCR
80072(a)(1)
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Personal rights 80072(a)(1)
Except for children’s residential facilities, each client shall have personal rights which include, but are not limited to, the following: To be accorded dignity in his/her personal relationships with staff and other persons.
Based on observation, interview and record review, this requirement was not met as evidenced by: The licensee did not ensure that the residents were accorded to dignity in their personal relationships with staff. This poses a potential Health, Safety, or Personal Rights risk to persons in care. The licensee states an in-service with all the staff on personal rights will be conducted.
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The Licensee agrees to conduct a staff in service on personal rights. Proof is to be submitterd to the department by 5pm on the due date indicated.
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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 EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javina GeorgeTELEPHONE: (951) 204-7107
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)
Page: 3 of 6
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
10/31/2019 and conducted by Evaluator Javina George
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20191031134929

FACILITY NAME:LA FUENTE LAVENDER 4FACILITY NUMBER:
361880611
ADMINISTRATOR:MELINDA HILARIOFACILITY TYPE:
740
ADDRESS:1155 N GLENWOOD AVETELEPHONE:
(909) 421-2561
CITY:RIALTOSTATE: CAZIP CODE:
92376
CAPACITY:0CENSUS: 0DATE:
09/29/2021
ANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Licensee Sotero Chandler RamasTIME COMPLETED:
10:30 AM
ALLEGATION(S):
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Staff caused an injury to a resident.
Facility is not following admission agreement.
Staff withholds services for resident as form of retaliation.
Staff allow resident to sit in a soiled diaper for extended periods of time.
Staff failed to assist resident after sustaining a fall.

INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Javina George met with Licensee at the Regional Office for the purpose of delivering findings for the above allegation(s). LPA George met with Licensee Sotero Chandler Ramas and advised the purpose of visit. Below is a summary of the findings of the investigation: The above allegation(s) were investigated by the department. The investigation consisted of interview of individuals connected to the facility and reviewed documentation that includes: a review of the facility's complaint history and Incident Reports.

Allegation #1 Staff caused an injury to a resident.
Facility history review revealed that all resident's in care were observed to be well and without any lesions or bruises. Based on information provided, observations and interviews conducted; the allegation that staff caused an injury to the resident is thereby deemed as UNSUBSTANTIATED.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javina GeorgeTELEPHONE: (951) 204-7107
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)
Page: 4 of 6
Control Number 18-AS-20191031134929
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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Allegation: Facility is not following admission agreement
The above complaint was investigated by the department. Based on review of documentation, and interviews conducted. A copy of the admission agreement provided shows a monthly rate of $2,000 was being charged for Resident #1 (R1). When Licensee Chandler was interviewed, he stated that “residents are paying anywhere from $2000-$2500. I have barely asked for an increase for the first time when minimum wage increased. The residents only got a $50 increase in their monthly rent. I'm going to be honest with you that sometimes I do struggle but there has not been an increase in two years prior to when I mentioned about the recent increase because of minimum wage. I sat and spoke with the residents and their family about why the increase and what they were able to pay”. The above allegation(s) of Facility is not following admission agreement is UNSUBSTANTIATED.

Allegation: Staff withholds services for resident as forms of retaliation.
The above complaint was investigated by the department. LPA reviewed information and feedback provided from interviews about how the needs of the residents are being met. Information or feedback provided was that the staff are gentle, and sensitive to the resident’s and their emotional needs. Per interviews conducted the staff are good to the resident’s and treat them well. There is not any evidence to support that the allegation of Staff withholds services for resident as forms of retaliation is UNSUBSTANTIATED.

Allegation: Staff allow resident to sit in a soiled diaper for extended periods of time.
Interviews conducted revealed that residents are being changed as soon as staff is made aware. In addition, facility documentation showed that residents are being physically checked every 2 hours. The allegation Staff allow resident to sit in a soiled diaper for extended periods of time is UNSUBSTANTIATED.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javina GeorgeTELEPHONE: (951) 204-7107
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)
Page: 5 of 6
Control Number 18-AS-20191031134929
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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Allegation: Staff failed to assist resident after sustaining a fall.
The above allegation(s) were investigated by the department. The investigation consisted of interviews of individuals connected to the facility, and record review. LPA reviewed narrative charting completed on 8/9/19 by facility staff. The information in the charting stated that resident #2 (R2) sustained a fall. There was also an LIC624 Special Incident Report (SIR) that was sent to the department via fax on 8/14/19. In addition, R2 was also sent out to the Kaiser Fontana Emergency Room for evaluation. Based in the preponderance of evidence; The allegation that Staff failed to assist resident after sustaining a fall 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 Chandler Sotero Ramas.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javina GeorgeTELEPHONE: (951) 204-7107
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)
Page: 6 of 6