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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 361880996
Report Date: 08/25/2021
Date Signed: 08/25/2021 02:17:03 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
08/23/2021 and conducted by Evaluator Melody Brown
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20210823113426
FACILITY NAME:TAMARIND SENIOR CARE, LLCFACILITY NUMBER:
361880996
ADMINISTRATOR:RAMAS, SOTERO CHANDLER IIIFACILITY TYPE:
740
ADDRESS:9545 TAMARIND AVETELEPHONE:
(909) 346-0292
CITY:FONTANASTATE: CAZIP CODE:
92335
CAPACITY:6CENSUS: 4DATE:
08/25/2021
UNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Sotero Chandler Ramas IIITIME COMPLETED:
02:45 PM
ALLEGATION(S):
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Resident lost ability to walk while in care.
Resident developed pressure injuries while in care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Melody Brown conducted an unannounced visit to the facility to commence a complaint investigation. LPA identified herself and discussed the purpose of the visit and the elements of the allegation(s) with Administrator Sotero Chandler Ramas III.

The investigation was conducted by LPA Melody Brown. The investigation consisted of records review and interviews with relevant parties. The first allegation indicates that due to neglect/lack of supervision, Resident 1 (R1) lost the ability to walk while under care. During the investigation, LPA Brown did not find evidence to corroborate the allegation. Records review and interview with hospice nurse indicated that R1 did not have a stroke or lose the ability to walk with assistance. In addition, hospice nurse indicated that R1 has history of stroke prior to moving into the facility last 08/13/2021 and was partially paralyze on the left side. Investigation also revealed that R1 did not have significant weight loss per hospice cares’ measurement of R1’s mid-arm circumference.


Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 248-0337
LICENSING EVALUATOR NAME: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:

DATE: 08/25/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2021
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 5
Control Number 18-AS-20210823113426
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: TAMARIND SENIOR CARE, LLC
FACILITY NUMBER: 361880996
VISIT DATE: 08/25/2021
NARRATIVE
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The second allegation indicates that due to neglect/lack of supervision, R1 developed pressure injuries while in care. During the investigation, LPA Brown did not obtain evidence to corroborate the allegation. Interview with hospice nurse, facility staff and records review indicated slight redness, but no pressure injuries were reported on R1’s body upon admission to the facility last 08/13/2021 or when R1 moved out of the facility last 08/17/2021.

Based on the evidence the allegation that R1 lost the ability to walk or developed a pressure injury while in care 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.
SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 248-0337
LICENSING EVALUATOR NAME: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:

DATE: 08/25/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 5
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
08/23/2021 and conducted by Evaluator Melody Brown
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20210823113426

FACILITY NAME:TAMARIND SENIOR CARE, LLCFACILITY NUMBER:
361880996
ADMINISTRATOR:RAMAS, SOTERO CHANDLER IIIFACILITY TYPE:
740
ADDRESS:9545 TAMARIND AVETELEPHONE:
(909) 346-0292
CITY:FONTANASTATE: CAZIP CODE:
92335
CAPACITY:6CENSUS: 4DATE:
08/25/2021
UNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Sotero Chandler Ramas IIITIME COMPLETED:
02:45 PM
ALLEGATION(S):
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Staff were not assisting resident with administration of medications.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Melody Brown conducted an unannounced visit to the facility to commence a complaint investigation. LPA identified herself and discussed the purpose of the visit and the elements of the allegation(s) with Administrator Sotero Chandler Ramas III.

The investigation was conducted by LPA Melody Brown. The investigation consisted of records review and interviews with relevant parties. The allegation indicates that staff were not assisting R1 with administration of medications. LPA Brown obtained evidence to corroborate the allegation above. Staff reported that all client medications are centrally stored and administered according to their physician’s orders. However, LPA Brown learned that no medication records existed for R1. The facility was unable to provide LPA Brown with any documentation showing when R1’s medications were dispensed as prescribed by R1’s physician.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 248-0337
LICENSING EVALUATOR NAME: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:

DATE: 08/25/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 18-AS-20210823113426
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: TAMARIND SENIOR CARE, LLC
FACILITY NUMBER: 361880996
VISIT DATE: 08/25/2021
NARRATIVE
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Database Link IconBased on LPA Brown’s observations and records review, the preponderance of evidence standard has been met, and therefore the above allegation of staff not assisting resident with administration of medications 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.

An exit interview was conducted where this report was discussed and provided to Administrator Sotero Chandler Ramas III.
SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 248-0337
LICENSING EVALUATOR NAME: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:

DATE: 08/25/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 18-AS-20210823113426
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: TAMARIND SENIOR CARE, LLC
FACILITY NUMBER: 361880996
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/25/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type A
08/26/2021
Section Cited
CCR
87465(7)
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When requested by prescribing physician or the Department, a record of dosages of meds which are centrally stored... This requirement wasn't met as evidenced by: Based on observation, the licensee didn't maintain a record of centrally stored prescription meds for R1 for 1 year.
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Licensee/Administrator will immediately create a system to record centrally stored medications for all residents.
Licensee/Administrator will train staff on medication recording and provide LPA Brown with proof of training by 08/26/2021.
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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: Efren MalagonTELEPHONE: (951) 248-0337
LICENSING EVALUATOR NAME: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:

DATE: 08/25/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 5