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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 366400567
Report Date: 10/12/2021
Date Signed: 10/12/2021 01:48:06 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
RIVERSIDE, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/14/2020 and conducted by Evaluator Crystal Colvin
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20201014131312
FACILITY NAME:SRI ENTERPRISES GRACEFUL HOUSEFACILITY NUMBER:
366400567
ADMINISTRATOR:SUTJININGSIH, SRIADIFACILITY TYPE:
735
ADDRESS:997 W. GROVE STREETTELEPHONE:
(909) 874-6711
CITY:RIALTOSTATE: CAZIP CODE:
92376
CAPACITY:4CENSUS: 3DATE:
10/12/2021
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Sriadi Sutjiningsih - Licensee/AdministratorTIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Facility failed to report to required agencies

Facility operating outside of conditions of license/fire clearance
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Crystal Colvin arrived at the facility for the purpose of deliering findings on a complaint with the above allegations. LPA Colvin met with Licensee/Administrator Sriadi Sutjiningsih and advised them of the purpose of today's inspection. Below is a summary of the findings:

Regarding allegation "Facility failed to report to required agencies" - LPA Colvin conducted a review of Incident Reports that had been submitted for this facility and observed that none had been submitted since October 2015. When asked about the absence of reports, the Licensee stated that they mailed them to Community Care Licensing (CCL), which LPA Colvin was not able to confirm. Additionally, it was revealed that the Licensee has also not been following proper reporting procedure for Inland Regional Center (IRC) regarding how to submit Incident Reports, despite having been recently corrected and instructed on the matter. Neither CCL nor IRC was informed by the Licensee in a timely manner of R1's fall having resulted in a fracture, which required surgery. Therefore, based on record review and interview, the allegation "Facility failed to report to required agencies" is SUBSTANTIATED.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Crystal Colvin
LICENSING EVALUATOR SIGNATURE:

DATE: 10/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2021
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
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
10/14/2020 and conducted by Evaluator Crystal Colvin
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20201014131312

FACILITY NAME:SRI ENTERPRISES GRACEFUL HOUSEFACILITY NUMBER:
366400567
ADMINISTRATOR:SUTJININGSIH, SRIADIFACILITY TYPE:
735
ADDRESS:997 W. GROVE STREETTELEPHONE:
(909) 874-6711
CITY:RIALTOSTATE: CAZIP CODE:
92376
CAPACITY:4CENSUS: DATE:
10/12/2021
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Sriadi Sutjiningsih - Licensee/AdministratorTIME COMPLETED:
02:00 PM
ALLEGATION(S):
1
2
3
4
5
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7
8
9
Staff neglect resulted in resident sustaining injury at facility requiring surgery

Neglect of resident resulting in bruising

INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Crystal Colvin arrived at the facility for the purpose of deliering findings on a complaint with the above allegations. LPA Colvin met with Licensee/Administrator Sriadi Sutjiningsih and advised them of the purpose of today's inspection. Below is a summary of the findings:

Regarding allegation "Staff neglect resulted in resident sustaining injury at facility requiring surgery" - On 9/29/20, Resident 1 (R1) fell on the facility's driveway after exiting the facility's vehicle. R1's fall resulted in a fractured leg which required surgery. During the investigation it was revealed that R1 walks with an uneven gait and has a history of rushing while walking, which is documented in R1's file at the facility. Through interviews conducted it was determined that R1's fall was an accident caused by R1 rushing after another resident who had exited the same vehicle and had already made it to the inside of the facility. There was no evidence present of neglect found, and it was confirmed that the Licensee took R1 to the hospital immediately after R1's fall. Therefore, due to record review and interviews, the allegation "Staff neglect resulted in resident sustaining injury at facility requiring surgery" is UNSUBSTANTIATED.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Crystal Colvin
LICENSING EVALUATOR SIGNATURE:

DATE: 10/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 18-AS-20201014131312
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: SRI ENTERPRISES GRACEFUL HOUSE
FACILITY NUMBER: 366400567
VISIT DATE: 10/12/2021
NARRATIVE
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Regarding allegation "Neglect of resident resulting in bruising" - R1 was observed to have bruising on their legs, which may or may not be a result of the fall that R1 sustained on 9/29/20. Interviews conducted revealed that R1, who is not used to navigating a wheelchair, has bumped into things while operating the wheelchair which has likely caused the bruising on R1. All persons interviewed denied R1 having multiple falls since R1's fall on 9/29/20 and deny any staff abuse to R1. No evidenced was observed during this investigation to suggest that R1 has been the victim of neglect. Therefore, due to interviews conducted, the allegation "Neglect of resident resulting in bruising" is UNSUBSTANTIATED.

A finding of 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.

LPA Colvin conducted an exit interview with Licensee/Administrator Sriadi Sutjiningsih and provided her with a copy of the report.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Crystal Colvin
LICENSING EVALUATOR SIGNATURE:

DATE: 10/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 18-AS-20201014131312
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: SRI ENTERPRISES GRACEFUL HOUSE
FACILITY NUMBER: 366400567
VISIT DATE: 10/12/2021
NARRATIVE
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Regarding allegation "Facility operating outside of conditions of license/fire clearance" - LPA Colvin conducted interviews with residents, staff, and outside parties in relation to the complaint. During the investigation it was revealed that R1's ambulatory status had changed from ambulatory to non-ambulatory, as R1 was using the assistance of a wheelchair while healing from a fractured leg. Interviews conducted stated that R1 had trouble navigating through the facility on their wheelchair and often bumped into objects, which subsequently causes bruising on R1's legs. The facility's fire clearance and license is limited to ambulatory residents only, and no request was submitted to Community Care Licensing (CCL) to request an exception for R1 while R1 healed from surgery. Therefore, based on interviews conducted, the allegation "Facility operating outside of conditions of license/fire clearance" is SUBSTANTIATED.

A finding that the complaint is SUBSTANTIATED means that the allegation(s) is valid because the preponderance of the evidence standard has been met.

Violations of a facility's fire clearance result in an immediate $500 civil penalty which LPA Colvin will be assessing today due to the substantiated allegation of "Facility operating outside of conditions of license/fire clearance".

An exit interview was conducted where this report and appeal rights were discussed. A copy of this report, LIC9099D, LIC421IM, and appeal rights was provided to Licensee/Administrator Sriadi Sutjiningsih during the exit interview.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Crystal Colvin
LICENSING EVALUATOR SIGNATURE:

DATE: 10/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 5
Control Number 18-AS-20201014131312
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: SRI ENTERPRISES GRACEFUL HOUSE
FACILITY NUMBER: 366400567
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/12/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/13/2021
Section Cited
CCR
80061(b)(1)(D)
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Reporting Requirements: (b) Upon the occurrence...a report shall be made to the licensing agency within the agency's next working day... (1) Events reported shall include...: (D) Any injury to any client which requires medical treatment. This requirement was not met as evidenced by:
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Licensee states that they will submit Incident Reports to CCL in accordance with guidelines. Licensee to submit Statement of Understanding regarding process to submit incident reports to CCL as well as statment confirming that they will submit all reports directly to CCL. Statement due by 10/13/21.
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Based on record review, the Licensee did not comply with the above regulation with one resident (R1). LPA Colvin observed that CCL had not received an incident reports regarding R1 having broken their leg or the need for surgery. This posed an immediate personal rights risk to R1.
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Type A
10/13/2021
Section Cited
CCR
80010(b)(1)
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Limitations on Capacity and Ambulatory Status: (b) Facilities or rooms approved for ambulatory clients only shall not be used by nonambulatory clients. (1) Clients whose condition becomes nonambulatory shall not use rooms or areas restricted to ambulatory clients. This requirement was not met by:
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Licensee states that they will create procedure where if resident changes in ambulatory status, a meeting will be held and the facility will contact CCL to request further guidance and possible change of Fire Clearance. Licensee to submit this new plan regarding ambulatory status changes by 10/13/21.
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Based on interviews, the Licensee did not comply with the above regulation with one resident (R1). Since R1's fall on 9/29/20, R1 has been non-ambulatory with use of a wheelchair. The facility does not have a fire clearance for non-ambulatory. This posed an immediate health and safety risk to R1.
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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.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Crystal Colvin
LICENSING EVALUATOR SIGNATURE:

DATE: 10/12/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 5