361881276-11-6-2023-56-AS-KCLS-D7MRLC-20240729130653

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 361881276
Report Date: 11/06/2023
Date Signed: 11/06/2023 03:52:01 PM

Unsubstantiated

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
10/31/2023 and conducted by Evaluator Bernadette Allen

COMPLAINT CONTROL NUMBER: 56-AS-20231031083549

FACILITY NAME:	MISSION COMMONS		FACILITY NUMBER:	361881276
ADMINISTRATOR:	THOMAS TAYLOR		FACILITY TYPE:	740
ADDRESS:	10 TERRACINA BOULEVARD		TELEPHONE:	(909) 793-8691
CITY:	REDLANDS	STATE: CA	ZIP CODE:	92373
CAPACITY:	59	CENSUS:	DATE:	11/06/2023
		UNANNOUNCED	TIME BEGAN:	12:15 PM
MET WITH:	Sarah Wolfe- Administrator		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Staff charged resident in care for services not provided
Staff did not provide housekeeping services to resident in care
Staff did not ensure resident in care was adequately hydrated
Staff did not provide adequate medication assistance to resident in care
Staff did not provide oral care to resident in care
Staff did not provide adequate supervision to resident in care

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPA)Bernadette Allen made an unannounced visit to the facility to investigate and deliver the findings for the allegations listed above. LPA met with Sarah Wolf Administrator, and she was informed of the purpose of the visit and alleged allegations.

The investigation consisted of interviews, observations, and documentation. LPA reviewed documents that revealed staff members are providing services stipulated in Resident 1(R1) needs and service plan. Records revealed staff does check on R1 at least seven (7) times a day or more.
Documents reviewed reflect staff members are assisting R1 with their ADL’s (assistance with daily living) daily and throughout the day ensuring that R1 is being encouraged to hydrate and water is available to drink at any time.

The interview with R1 stated they only hydrate when thirsty but staff are always telling them to drink water.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Bernadette Allen	TELEPHONE: 951-897-2618
LICENSING EVALUATOR SIGNATURE:	DATE: 11/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 56-AS-20231031083549

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: 11/06/2023

NARRATIVE

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LPA also observed a half cup of water on the side of bed and R1 stated the other half was drank earlier and it would be finished later. Staff has also stated R1 is reminded of oral care daily and assist if allowed. Staff has also stated R1 is assisted with medications and adequate supervision is being provided daily.

LPA toured R1’s apartment and it was clean and free clutter and odors. The floor in the dining area was clean free of stains and not wet. There were no dishes in the sink and the carpet in room was free of spots and staff confirmed the carpet was cleaned recently.

Based on the interviews, observations, and record review the above finding is 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.

An exit interview was conducted and discussed with Sarah Wolfe and a copy of the report with appeal rights was provided at the conclusion of the visit.

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Bernadette Allen	TELEPHONE: 951-897-2618
LICENSING EVALUATOR SIGNATURE:	DATE: 11/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2023

LIC9099 (FAS) - (06/04)

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