361881026-1-13-2023-56-AS-KCLS-CP5UP8-20230217144507

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 361881026
Report Date: 01/13/2023
Date Signed: 01/13/2023 01:43:13 PM

Substantiated

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
, CA 92507

This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/09/2022 and conducted by Evaluator Rayshaun Nickolas

PUBLIC

COMPLAINT CONTROL NUMBER: 56-AS-20220509085953

FACILITY NAME:	HESPERIA SENIOR CARE		FACILITY NUMBER:	361881026
ADMINISTRATOR:	WANG, JIN A		FACILITY TYPE:	740
ADDRESS:	17583 SULTANA STREET		TELEPHONE:	(760) 669-0109
CITY:	HESPERIA	STATE: CA	ZIP CODE:	92345
CAPACITY:	18	CENSUS: 8	DATE:	01/13/2023
		UNANNOUNCED	TIME BEGAN:	12:05 PM
MET WITH:	Raeanne Rios, Caregiver		TIME COMPLETED:	01:46 PM

ALLEGATION(S):

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Unqualified staff dispensing medication

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Rayshaun Nickolas made an unannounced visit to the facility to deliver the finding on the above allegation. LPA met with Raeanne Rios and explained the purpose of the visit. Rios called the Licensee, and the Licensee was unavailable to attend. LPA obtained permission from the Licensee to discuss this report with Rios and for Rios to sign the report on their behalf. The investigation consisted of file reviews and interviews with relevant parties.

The allegation alleges that on April 5, 2022, or April 6, 2022, a member of the facility's staff was overheard reprimanding, screaming, and crying about the staff working at the facility not qualified to dispense medication. An interview with the Licensee revealed that only the certified nursing assistants (CNAs) working at the facility could dispense medication, not caregivers. The Licensee stated that care and compliance Compact disc (CD) training was provided to staff and provided proof of the staff’s training record. However, page nine (9) of the facility’s program description on medication training states, “any staff member assisting residents with the self-administration of medication are required to complete six (6) hands-on shadowing hours before working independently with a resident.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Rayshaun Nickolas	TELEPHONE: 951-255-9516
LICENSING EVALUATOR SIGNATURE:	DATE: 01/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/13/2023

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 5

Control Number 56-AS-20220509085953

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
, CA 92507

FACILITY NAME: HESPERIA SENIOR CARE	FACILITY NUMBER: 361881026
	VISIT DATE: 01/13/2023

NARRATIVE

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An additional four (4) hours of initial medication training must also be completed within the first two (2) weeks of medication staff employment”. Page nine (9) of the facility’s program description on medication training further states, “after completing ten (10) hours of training, the employees will be tested on their comprehension and competency in medication assistance. The test result will be filed in the employee’s personnel file. In each succeeding twelve (12) month period, an additional eight (8) hours of training will be conducted with the employee on medication-related issues”. The Licensee failed to provide sufficient evidence that staff dispensing medication were qualified as outlined in the facility’s program description.

Based on the evidence gathered during the investigation, the above allegation is 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 conduct were a copy of this report (LIC 9099), LIC 9099D, and appeal rights were discussed and provide.

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Rayshaun Nickolas	TELEPHONE: 951-255-9516
LICENSING EVALUATOR SIGNATURE:	DATE: 01/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/13/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 5

Control Number 56-AS-20220509085953

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
, CA 92507

FACILITY NAME: HESPERIA SENIOR CARE	FACILITY NUMBER: 361881026
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/13/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 01/27/2023 Section Cited CCR 87208(a)(6)	1 2 3 4 5 6 7	87208 Plan of Operation (a)(6) (6) Plan for training staff, as required by Section 87411(c). This requirement was not met as evidenced by:	1 2 3 4 5 6 7	The Licensee shall read section 87208(a)(6) and 87411(c) of the California Code of Regulation (CCR). Licensee shall submit a letter of understanding to the Regional Office (RO) by the POC due date.
	8 9 10 11 12 13 14	Based on file review & interview, the Licensee did not ensure that staff training and proof of staff training were followed as outlined in the facility's program description on medication training.	8 9 10 11 12 13 14
	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: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Rayshaun Nickolas	TELEPHONE: 951-255-9516
LICENSING EVALUATOR SIGNATURE:	DATE: 01/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/13/2023

LIC9099 (FAS) - (06/04)

Page: 3 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
, CA 92507

This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/09/2022 and conducted by Evaluator Rayshaun Nickolas

PUBLIC

COMPLAINT CONTROL NUMBER: 56-AS-20220509085953

FACILITY NAME:	HESPERIA SENIOR CARE		FACILITY NUMBER:	361881026
ADMINISTRATOR:	WANG, JIN A		FACILITY TYPE:	740
ADDRESS:	17583 SULTANA STREET		TELEPHONE:	(760) 669-0109
CITY:	HESPERIA	STATE: CA	ZIP CODE:	92345
CAPACITY:	18	CENSUS: 8	DATE:	01/13/2023
		UNANNOUNCED	TIME BEGAN:	12:05 PM
MET WITH:	Raeann Rios, Caregiver		TIME COMPLETED:	01:46 PM

ALLEGATION(S):

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Resident sustained injury while in care
Staff are not adequately trained
Staff did not notice a change in resident's condition
Staff yelling at resident

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Rayshaun Nickolas made an unannounced visit to the facility to deliver the finding on the above allegations. LPA met with Raeanne Rio’s and explained the purpose of the visit. Rios called the Licensee, and the Licensee was unavailable to attend. LPA obtained permission from the Licensee to discuss this report with Rios and for Rios to sign the report on their behalf. The investigation consisted of file reviews and interviews with relevant parties.

Allegation #1 “Resident sustained injury while in care” The allegation alleges that on April 5, 2022, or April 6, 2022, the reporting party (RP) was visiting their friend client # 2 (C2) and observed client # 1 (C1) lying on the floor in their room and bleeding badly at the top of their head. LPA interview with the Licensee revealed that C1 did not suffer any injury on any of the alleged dates. The investigation into this incident revealed insufficient evidence to corroborate the allegation.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Rayshaun Nickolas	TELEPHONE: 951-255-9516
LICENSING EVALUATOR SIGNATURE:	DATE: 01/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/13/2023

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 5

Control Number 56-AS-20220509085953

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
, CA 92507

FACILITY NAME: HESPERIA SENIOR CARE	FACILITY NUMBER: 361881026
	VISIT DATE: 01/13/2023

NARRATIVE

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Allegation #2 “Staff are not adequately trained”. The allegation alleges that on April 5, 2022 or April 6, 2022, the RP does not believe that the facility staff received proper training based on the reprimand they overheard from a staff member that quit. LPA interview with Licensee revealed that staff was provided compact disc (CD) training from a company called Care and Compliance group. The Licensee also provided documentation of facility staff training. LPA interview with facility staff #2 (S2) revealed that Digital Versatile Disk (DVD) training videos were provided. The investigation into this incident revealed insufficient evidence to corroborate the allegation.

Allegation # 3 “Staff did not notice a change in resident's condition”. The allegation alleges that on April 5, 2022 or April 6, 2022, C1 was observed by the RP lying on the floor. RP states that C1 was lying on the floor in their room and bleeding badly at the top of their head. The RP further stated that C1 lay on the floor for some time, and staff did not check on them or notice any changes in their condition. LPA interview with the Licensee revealed that C1 did not suffer any injury on any of the alleged dates. LPA interview with staff #1 (S1) revealed that C1 did fall, but S1 did not remember the exact date. However, S1 did provide a time frame, using weeks, and that time frame excluded April 5, 2022, or April 6, 2022. S1 also stated that 911 and the house manager were called when C1 fell. The investigation into this incident revealed insufficient evidence to corroborate the allegation.

Allegation #4 “Staff yelling at resident”. The allegation alleges that on April 5, 2022 or April 6, 2022, The RP overheard staff yelling at a resident. LPA interview with the Licensee revealed that no client or another member of the Licensee’s staff has ever reported to the Licensee that staff is yelling at a resident. LPA interview with S2 revealed that they had not received complaints from staff or clients about staff yelling at a resident. The investigation into this incident revealed insufficient evidence to corroborate the allegation.

Based on the investigation, the above findings are Unsubstantiated. A finding of unsubstantiated means 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.

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Rayshaun Nickolas	TELEPHONE: 951-255-9516
LICENSING EVALUATOR SIGNATURE:	DATE: 01/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/13/2023

LIC9099 (FAS) - (06/04)

Page: 5 of 5