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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 361880919
Report Date: 12/27/2023
Date Signed: 12/27/2023 02:27:54 PM

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
11/14/2023 and conducted by Evaluator Mary Rico
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20231114102757
FACILITY NAME:LOVE 2 CARE HOMESFACILITY NUMBER:
361880919
ADMINISTRATOR:JACKSON, TERRIFACILITY TYPE:
740
ADDRESS:19432 US HIGHWAY 18TELEPHONE:
(760) 297-6277
CITY:APPLE VALLEYSTATE: CAZIP CODE:
92307
CAPACITY:6CENSUS: 5DATE:
12/27/2023
UNANNOUNCEDTIME BEGAN:
11:54 AM
MET WITH:Care Giver Eula Jones and Tiffany ZollerTIME COMPLETED:
02:45 PM
ALLEGATION(S):
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Staff do not provide resident activities
Staff do not provide residents adequate food service
Staff transferred resident incorrectly
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Mary Rico conducted an unannounced visit to deliver findings on the allegations listed above. LPA met with Care Giver Eula Jones and explained the purpose of the visit. The investigation consisted of staff interviews, resident interviews, document reviews, and facility tour.

For the allegation, staff do not provide resident activities.

During interviews with residents, 4 out of the 5 residents stated the facility does not provide activities for them. R1 and R2 informed LPA the facility only provides a crossword sheet. R1 informed LPA they have offered ideas on what activities they should provide but the facility does not have enough staff. R1 stated the facility does not provide the activities that is listed on their calendar. In addition, R3 informed LPA they would prefer for the facility to provide exercise activities.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Mary Rico
LICENSING EVALUATOR SIGNATURE:

DATE: 12/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/27/2023
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 4
Control Number 56-AS-20231114102757
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: LOVE 2 CARE HOMES
FACILITY NUMBER: 361880919
VISIT DATE: 12/27/2023
NARRATIVE
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During interview with staff, 4 out the 5 staff informed LPA they do not provide activities for the residents. S1 informed LPA they provide crosswords sheets to residents, but no full activities that listed on the calendar. S2 informed LPA they are not able to provide activities because the facility has one staff per shift.

For the allegation, staff do not provide residents adequate food service.

During interviews with resident 4 out of the 5 residents stated the facility does not provide adequate food service. R1 informed LPA the facility does not follow the menu they provide. R1 stated the facility does not provide variety of foods considering their preference. R2 informed LPA they have suggested what meals they would like to receive, but facility does not accommodate their preference. R3 stated the facility food is not cooked properly and provided the same meal. In addition, R2 and R3 stated the facility does not provide what the menu states.

During interviews with staff, 4 out the 5 staff informed LPA they do follow the menu that is provided to the residents. S1 and S2 stated the facility will not have the right indigents to create the dish. S1 and S2 stated they are not able to follow the facility menu because they do not have correct foods to create the dish.

For the allegation, staff transferred resident incorrectly.

During interviews with resident, 3 out of the 5 residents stated the staff transferred them incorrectly. R1 and R2 stated they require a two-person transfer with a Hoyer lift. Both residents stated they have been transferred by one person. R1 informed LPA the facility will have one staff on the shifts conducting all transfers by themselves. Both residents stated they did not allow for staff members to transfer them without two people. During interviews with staff 4 out of the 5 staff members admitted they have transfer residents incorrectly. 4 out the 5 staff members stated they are not able to be transferred residents correctly due to one staff member working per shift. Staff also indicated R1 and R2 are a two person Hoyer lift but are not able to provide two-person transfer due to staffing. 3 out of the 5 staff stated they were aware R1 did not want to be transferred by one person.

Based on the evidence gathered during today’s investigation, the three (3) allegations listed above are deemed SUBSTANTIATED. A finding that the complaints are SUBSTANTIATED means that the allegations are valid because the preponderance of evidence the standard has been met .During today’s visit, three (3) deficiency were cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted, and this report (LIC9099) and LIC9099D was discussed and provided to care giver Tiffany Zoller, along with a copy of the appeal rights

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Mary Rico
LICENSING EVALUATOR SIGNATURE:

DATE: 12/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/27/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 56-AS-20231114102757
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: LOVE 2 CARE HOMES
FACILITY NUMBER: 361880919
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/27/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/10/2024
Section Cited
CCR
8755(b)(5)
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87555(b)(5) General Food Service Requirements(5)Meals shall consist of an appropriate variety of foods and shall be planned with consideration for cultural and religious background and food habits of residents.
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Adminstrator will send LPA a food menu that includes residents cultural and food habits. Administrator will provide LPA what days the facility will go grocery shopping to ensure staff members are able to provide the dish listed on resident menu.
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This requirement was not met based on document review, interviews by not having planned melas consideration of resdients background and food habits which poses a potential health, safety, or personal rights risk to persons in care.
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POC due date 1/10/2024.
Type B
01/10/2024
Section Cited
CCR
87219(b)
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87219(b)Planned Activites
Residents served shall be encouraged to contribute to the planning, preparation, conduct, clean-up and critique of the planned activities.
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Administrator will send LPA their updated Planned Activites. Administartor will send LPA they have trained their staff to provide activities.
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This requirement was not met based on document review, interviews by not having encouraged residents to contribute and planned activities which poses a potential health, safety, or personal rights risk to persons in care.
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POC due date 1/10/2024.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Mary Rico
LICENSING EVALUATOR SIGNATURE:

DATE: 12/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/27/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 56-AS-20231114102757
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: LOVE 2 CARE HOMES
FACILITY NUMBER: 361880919
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/27/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/03/2024
Section Cited
CCR
87468.1(a)(2)
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87468.1 Personal Rights of Residents in All Facilities
(2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.
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Administrator will send LPA they have understood and read the regulation. Administrator will train staff how to transfer resident safely and will not violate their personal rights. Administartor will ensure there are two staff memebers to provide a two-person transfer.
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This requirement was not met based on document review, interviews by staff not conducting a safe transfer for R1 and R2 which poses an immediate health, safety, or personal rights risk to persons in care.
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POC 1/3/2024
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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.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Mary Rico
LICENSING EVALUATOR SIGNATURE:

DATE: 12/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/27/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 4