361880860-12-31-2020-18-AS-EMAN-C92RFU-20211123115941

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 361880860
Report Date: 12/29/2020
Date Signed: 12/31/2020 03:17:41 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
12/22/2020 and conducted by Evaluator Stephanie Williams

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20201222095711

FACILITY NAME:	ALPHALIFE HOMECARE		FACILITY NUMBER:	361880860
ADMINISTRATOR:	SALDIVAR, BRYANT J		FACILITY TYPE:	740
ADDRESS:	9154 BELLFAST ROAD		TELEPHONE:	(909) 601-5154
CITY:	APPLE VALLEY	STATE: CA	ZIP CODE:	92308
CAPACITY:	12	CENSUS: 3	DATE:	12/29/2020
		UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Bryant Saldivar		TIME COMPLETED:	04:45 PM

ALLEGATION(S):

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9

Staff did not seek timely medical care for resident
Staff did not inform authorized representative of residents fall
Resident sustained a fall with injury
Administrator is not at the facility the required amount of time
Administrator is not returning residents personal belongings to authorized representative

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Stephanie Williams contacted the facility in order to initiate a complaint investigation into the above allegations via telephone due to the COVID-19 pandemic. LPA identified and spoke with the Administrator, Bryant Saldivar. LPA discussed the purpose of the call and elements of the allegations with Saldivar. The investigation consisted of interviews with staff and residents.

In regards to allegation #1, #2, & #3, LPA interviewed Staff #1 (S1) and Staff #2 (S2) who denied that staff did not seek medical care for Resident #1 (R1) in a timely manner. S1 and S2 both denied that R1 experienced a fall while in care at the facility, therefore; there was no information to notify R1's responsible party. S1 and S2 both stated that the facility is in constant communication with residents responsible parties.

In regards to allegation #4, LPA interviewed S1 who stated that the Administrator lives in the facility and is there often. LPA also interviewed S2 who stated that the Administrator lives at the facility and is at the

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 248-0337
LICENSING EVALUATOR NAME: Stephanie Williams	TELEPHONE: (951) 248-0317
LICENSING EVALUATOR SIGNATURE:	DATE: 12/29/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/29/2020

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-20201222095711

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: ALPHALIFE HOMECARE	FACILITY NUMBER: 361880860
	VISIT DATE: 12/29/2020

NARRATIVE

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facility a sufficient amount of time.

In regards to allegation #5, LPA interviewed S1 who stated that the facility has arranged with R1's responsible party several times to have them pick up R1's belongings; however, the belongings were not picked up. LPA interviewed Responsible Party #1 (RP1) who confirmed that the facility staff have attempted to have R1's belongings returned.

Based on evidence obtained during today’s tele-visit, LPA has determined that the above allegations are UNSUBSTANTIATED; meaning that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur.

An exit interview was conducted with the Administrator where this copy was discussed via telephone. A copy of this report was provided to the Administrator via email.

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 248-0337
LICENSING EVALUATOR NAME: Stephanie Williams	TELEPHONE: (951) 248-0317
LICENSING EVALUATOR SIGNATURE:	DATE: 12/29/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/29/2020

LIC9099 (FAS) - (06/04)

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