366404041-6-14-2021-18-AS-JESL-C992V6-20211129164325

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 366404041
Report Date: 06/14/2021
Date Signed: 06/14/2021 03:23:17 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
07/21/2020 and conducted by Evaluator Javina George

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20200721142056

FACILITY NAME:	SANTA FE TRAIL ASSISTED LIVING CENTER		FACILITY NUMBER:	366404041
ADMINISTRATOR:	MICHAEL GARCIA		FACILITY TYPE:	740
ADDRESS:	55425 SANTA FE TRAIL		TELEPHONE:	(760) 365-0887
CITY:	YUCCA VALLEY	STATE: CA	ZIP CODE:	92284
CAPACITY:	85	CENSUS: 63	DATE:	06/14/2021
		UNANNOUNCED	TIME BEGAN:	02:30 PM
MET WITH:	Administrator Michael Garcia		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Facility did not safeguard resident's personal records.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Javina George contacted the facility for the purpose of delivering findings for the above allegation. LPA George met with Jennifer Levesque and advised the purpose of visit. Below is a summary of the findings of the investigation:

Based on a review of information gathered from supporting documents, and interviews conducted. LPA George was able to corroborate the allegation. LPA George received and reviewed documentation, that was found blowing around outside the facility and in surrounding areas. The documentation revealed multiple resident's that were placed at the facility during 2013. The information was personal records such as medication for credit form, drug disposition record, change of condition form and a list of resident's that receive PM medications at 5pm, 8pm and 10pm were not safeguarded. Based on the documentation received the allegation of Facility did not safeguard resident's personal records is SUBSTANTIATED.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Joel Esquivel	TELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javina George	TELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:	DATE: 06/14/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2021

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 18-AS-20200721142056

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: SANTA FE TRAIL ASSISTED LIVING CENTER	FACILITY NUMBER: 366404041
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/14/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 09/01/2020 Section Cited CCR 87506	1 2 3 4 5 6 7	Personal Records (c) All information and records obtained from or regarding residents shall be confidential. (1) The licensee shall be responsible for storing active and inactive records and for safeguarding the confidentiality of their contents...	1 2 3 4 5 6 7	This requirement was not met as evidenced by the facility having disharged clients documents personal information being outside of the facility and throughout the neighborhood.
	8 9 10 11 12 13 14	This requirement is not met as evidenced by:Based on observation, interviews and record review, the licensee did not ensure that multiple resident's personal records were properly disposed. Numerous document that were not safeguarded.	8 9 10 11 12 13 14	The Administrator will review the facility personal records procedure including discharge files with all staff. Proof will be submitted to the department by 5pm on the due date indicated.
	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: Joel Esquivel	TELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javina George	TELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:	DATE: 06/14/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2021

LIC9099 (FAS) - (06/04)

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Control Number 18-AS-20200721142056

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: SANTA FE TRAIL ASSISTED LIVING CENTER	FACILITY NUMBER: 366404041
	VISIT DATE: 06/14/2021

NARRATIVE

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A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

Based on the complaint investigation, deficiencies were observed in the areas evaluated and cited according to California Code of Regulations, Title 22, Division 6 and listed on the attached LIC 9909D.

An exit interview was conducted and a copy of this report, 9099C and 9099D was given to Assistant Administrator Michael Garcia.

SUPERVISOR'S NAME: Joel Esquivel	TELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javina George	TELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:	DATE: 06/14/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2021

LIC9099 (FAS) - (06/04)

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