361881276-5-29-2024-56-AS-EMAN-D5SJUU-20240531072204

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 361881276
Report Date: 05/29/2024
Date Signed: 05/29/2024 11:22:15 AM

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
12/18/2023 and conducted by Evaluator Melody Brown

PUBLIC

COMPLAINT CONTROL NUMBER: 56-AS-20231218142533

FACILITY NAME:	MISSION COMMONS		FACILITY NUMBER:	361881276
ADMINISTRATOR:	SARAH WOLFE		FACILITY TYPE:	740
ADDRESS:	10 TERRACINA BOULEVARD		TELEPHONE:	(909) 793-8691
CITY:	REDLANDS	STATE: CA	ZIP CODE:	92373
CAPACITY:	59	CENSUS: 8	DATE:	05/29/2024
		UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Executive Director Sarah Wolfe		TIME COMPLETED:	11:30 AM

ALLEGATION(S):

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Staff did not report an incident involving resident while in care.

INVESTIGATION FINDINGS:

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On 05/29/2024 at 10:30 AM, Licensing Program Analyst (LPA) Melody Brown conducted an unannounced visit to the facility to deliver the findings of the above allegations. LPA Brown was greeted and granted entrance by a staff at the reception area and met with Executive Director (ED) Sarah Wolfe. LPA Brown identified herself and discussed the purpose of the visit and the elements of the allegations with ED Wolfe.

The investigation was conducted by LPA Melody Brown. The investigation consisted of records review and interviews with relevant parties. The allegation indicates that Staff did not report an incident involving resident while in care. LPA Brown obtained evidence to corroborate the allegation above. Interviews with Staff #3 (S3), Staff #4 (S4), Staff # 5 (S5) and Staff #6 (S6) at the facility on 05/15/2024 indicated all of them are reporting incidents involving residents at the facility but their Directors are responsible on submitting incident reports. ***Continuation on LIC90999C***

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody Brown	TELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:	DATE: 05/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/29/2024

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 5

Control Number 56-AS-20231218142533

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: MISSION COMMONS	FACILITY NUMBER: 361881276
	VISIT DATE: 05/29/2024

NARRATIVE

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Documents review revealed that on 06/14/2023, the facility noted Resident #1 (R1) fell in the bathroom of another resident in Independent Living. In addition, R1 was reported intoxicated with another resident. LPA Brown cross reference Community Care Licensing Division (CCLD) Unusual Incident Report Log and no Incident Report was submitted for R1 on the specified date within seven (7) days. Interview with S1 indicated that because R1 did not go out of the community after the fall, that staff did not call 911 for R1, the facility did not submit an incident report to CCLD.

Based on LPA Brown’s observations and records review, the preponderance of evidence standard has been met, and therefore the above allegation of Staff did not report an incident involving resident while in care 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. California Code of Regulations, (Title 22, Division 6 & Chapter 8) is being cited on the attached LIC9099D.

An exit interview was conducted where this report, LIC9099, LIC9099D, and Appeal Rights were discussed and provided to Executive Director Sarah Wolfe.

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody Brown	TELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:	DATE: 05/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/29/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 5

Control Number 56-AS-20231218142533

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: MISSION COMMONS	FACILITY NUMBER: 361881276
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/29/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 06/07/2024 Section Cited CCR 87211(a)(1)(D)	1 2 3 4 5 6 7	87211 Reporting Requirements(a) Each licensee shall furnish to the licensing agency such reports as the Department may require...(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date...(D) Any incident which threatens the welfare, safety or health of any resident... This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Licensee stated to submit Signed Statement of Understanding on CCR 87211(a)(1)(D) and submit proof to LPA Brown on POC due date.
	8 9 10 11 12 13 14	Based on observation, interview and records review, the Licensee did not comply with the section cited above by not submitting an incident report for Resident #1 within seven (7) days of the incident on 06/14/2023 to Community Care Licensing Division (CCLD) which pose potential health, safety and personal rights risk to residents in care.	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: Efren Malagon	TELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody Brown	TELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:	DATE: 05/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/29/2024

LIC9099 (FAS) - (06/04)

Page: 5 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
12/18/2023 and conducted by Evaluator Melody Brown

PUBLIC

COMPLAINT CONTROL NUMBER: 56-AS-20231218142533

FACILITY NAME:	MISSION COMMONS		FACILITY NUMBER:	361881276
ADMINISTRATOR:	SARAH WOLFE		FACILITY TYPE:	740
ADDRESS:	10 TERRACINA BOULEVARD		TELEPHONE:	(909) 793-8691
CITY:	REDLANDS	STATE: CA	ZIP CODE:	92373
CAPACITY:	59	CENSUS: 8	DATE:	05/29/2024
		UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Executive Director Mary Wolfe		TIME COMPLETED:	11:30 AM

ALLEGATION(S):

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Facility operated without an Administrator.
Staff did not prevent an unauthorized visitor from accessing resident while in care.

INVESTIGATION FINDINGS:

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On 05/29/2024 at 10:30 AM, Licensing Program Analyst (LPA) Melody Brown conducted an unannounced visit to the facility to deliver the findings of the above allegations. LPA Brown was greeted and granted entrance by a staff at the reception area and met with Executive Director (ED) Sarah Wolfe. LPA Brown identified herself and discussed the purpose of the visit and the elements of the allegations with ED Wolfe.

The investigation was conducted by LPA Melody Brown. The investigation consisted of observation, review of records and interviews with relevant parties. The first allegation indicates that Facility operated without an Administrator. During the investigation, LPA Brown did not find evidence to corroborate the allegation. Interviews with six (6) of six (6) staffs indicated that the facility never operated without an Administrator. Interviews with seven (7) of seven (7) residents indicated that they always observed different managers in-charged of the facility and no days that no one operated the facility. *** Continuation in LIC9099C ***

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody Brown	TELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:	DATE: 05/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/29/2024

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 56-AS-20231218142533

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: MISSION COMMONS	FACILITY NUMBER: 361881276
	VISIT DATE: 05/29/2024

NARRATIVE

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LPA Brown unable to interview R1 as R1 moved out on 02/28/2024. Per documents review, LPA Brown observed that Jonathan Karp is the Administrator of the facility and has a valid Residential Care for the Elderly (RCFE) Certification with expiry date of 10/30/2023. Also, Executive Director Sarah Wolfe reported started working at the facility as an Administrator/Executive Director on 09/11/2023.

The second allegation indicates Staff did not prevent an unauthorized visitor from accessing resident while in care. Interviews with seven (7) of seven (7) residents indicated that staffs at the facility are preventing unauthorized visitors from accessing resident while in care. LPA Brown unable to interview R1 as R1 moved out on 02/28/2024. Interviews with six (6) of six (6) staffs indicated they are preventing unauthorized visitor from accessing resident while in care. Interviews with staffs revealed that they have a Sign-in and Sign out Sheet at their Reception area that screen all visitors at the facility. Moreover, per documents review, LPA Brown observed that R1's Power of Attorney (POA) signed Release of Medical Information to a Hospice agency which gave them permission to contact R1 and provide information to R1 of their services.

Based on the evidence, the allegation that Staff do not ensure that Facility operated without an Administrator (Allegation #1) and Staff did not prevent an unauthorized visitor from accessing resident while in care (Allegation #2) are 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.

An exit interview was conducted where this report, LIC9099 was discussed and provided to Executive Director Sarah Wolfe.

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody Brown	TELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:	DATE: 05/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/29/2024

LIC9099 (FAS) - (06/04)

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