361880964-1-22-2024-56-AS-NBRN-CZRVBU-20240123151803

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 361880964
Report Date: 01/22/2024
Date Signed: 01/22/2024 11:44:27 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
01/17/2024 and conducted by Evaluator Amber Coleman

PUBLIC

COMPLAINT CONTROL NUMBER: 56-AS-20240117121131

FACILITY NAME:	CADENCE AT RANCHO CUCAMONGA		FACILITY NUMBER:	361880964
ADMINISTRATOR:	PENDING		FACILITY TYPE:	740
ADDRESS:	10459 CHURCH STREET		TELEPHONE:	(909) 918-5546
CITY:	RANCHO CUCAMONGA	STATE: CA	ZIP CODE:	91730
CAPACITY:	117	CENSUS: 110	DATE:	01/22/2024
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Krystal Jenkins, Vice President		TIME COMPLETED:	11:45 AM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Resident eloped from facility without staff knowledge sustaining an injury.

INVESTIGATION FINDINGS:

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

Licensing Program Analyst, Amber Coleman, (LPA) arrived at the Cadence at Rancho Cucamonga unannounced to initiate a complaint investigation into the allegation listed above. LPA entered the building, introduced self and stated the purpose of the visit. LPA was informed the Administrator is out for the week, the Memory Care Director was also out. LPA met with Vice President, Krystal Jenkins, who accompanied LPA to the Memory Care Unit.

During today's visit, LPA walked through the facility memory care unit, interviewed staff and collected pertinent documentation. It is alleged that a resident eloped from the facility without staff knowledge sustaining an injury. During, staff interviews, LPA learned that on the evening of 1/15/23 R1 left the memory care unit through it's courtyard. R1 then walked to the Del Taco on the corner of the nearest intersection. When staff was made aware R1 had left the facility, staff attempted to pick her up, but R1 suffered an injury on her knee and was taken to the hospital. Since the elopement, the facility has increased R1's supervision and added new door alarms to the courtyard entrances. The resident's family contracted home health services for one on one supervision. **Please see LIC9099-C

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: 01/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/22/2024

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 3

Control Number 56-AS-20240117121131

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: CADENCE AT RANCHO CUCAMONGA	FACILITY NUMBER: 361880964
	VISIT DATE: 01/22/2024

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

R1's family has also agreed to increase the number of visits and outings with the resident. The incident was communicated to R1's Physician, who is making adjustments to R1's medications to aid in the prevention of wandering. A record review of R1's file revealed that the resident is unable to leave the facility without supervision. Also, R1 has a history of wandering. LPA also reviewed the facility's staff schedule and found that the facility is adequately staffed for the number of residents in care. After the incident occurred, the facility provided staff an in-service training in elopement which reviewed facility protocol for resident elopement.

Based on LPA's observations, record reviews and staff interviews, we have substantiated the complaint allegation(s) as valid and that a violation has occurred based on the preponderance of available evidence. A deficiency will be cited to address the above mentioned concerns. A copy of this report along with appeal rights are being reviewed with, and furnished to the facility representative.

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Amber Coleman	TELEPHONE: 951-248-0338
LICENSING EVALUATOR SIGNATURE:	DATE: 01/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/22/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 56-AS-20240117121131

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: CADENCE AT RANCHO CUCAMONGA	FACILITY NUMBER: 361880964
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/22/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 01/22/2024 Section Cited CCR 80078)a)	1 2 3 4 5 6 7	80078 Responsibility for Providing Care and Supervision (a) The licensee shall provide care and supervision as necessary to meet the client's needs. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	A plan of correction was already implemented - The facility increased supervision, R1's family hired a home health agency to provide additional supervision. R1's family also agreed to increasing the number of viisit and outings. R1's physician was notified and
	8 9 10 11 12 13 14	Based on record reviews and staff interviews, staff did not provide adequate care and supervision for R1 on 1/15/24, when the resident left the facility on foot without supervision or knowledge R1 had eloped. The poses an immediate Health, Safety or Personal Rights risk to persons in care	8 9 10 11 12 13 14	will adjust medications Additionally, the facility has installed additonal door alarms/ motion censors. Lastly, the facility has provided an In-service (additional training) with elopement and procedures.
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: 01/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/22/2024

LIC9099 (FAS) - (06/04)

Page: 3 of 3