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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 366404041
Report Date: 06/14/2021
Date Signed: 10/28/2021 12:40:27 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
03/24/2020 and conducted by Evaluator Javina George
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20200324194548
FACILITY NAME:SANTA FE TRAIL ASSISTED LIVING CENTERFACILITY NUMBER:
366404041
ADMINISTRATOR:MICHAEL GARCIAFACILITY TYPE:
740
ADDRESS:55425 SANTA FE TRAILTELEPHONE:
(760) 365-0887
CITY:YUCCA VALLEYSTATE: CAZIP CODE:
92284
CAPACITY:85CENSUS: DATE:
06/14/2021
UNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Administrator Michael GarciaTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Facility is malodorous.
Facility does not have sufficient staff.
Facility failed to report incident to CCL.

INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Javina George called the facility for the purpose of delivering findings for the above allegation. LPA George met with Administrator Michael Garcia and advised the purpose of visit. Below is a summary of the findings of the investigation:
The above allegation(s) were investigated by the department. The investigation consisted of interviews of numerous interviews, and obtaining pertinent documentation that includes: a review of the facility's complaint history and SIRs.

Allegation #1: Facility is malodorous.
LPA conducted interviews, and file reviews. Based on the information provided from multiple sources. There is a strong odor of urine in the resident bedrooms, others stated that there is an odor in hallways, particularly in memory care. Staff stated that some resident's in memory care get confused and use the restroom in their closets. Based on information that allegation of Facility is Malodorous is SUBSTANTIATED.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javina GeorgeTELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:

DATE: 06/30/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/30/2020
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 4
Control Number 18-AS-20200324194548
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 A
06/15/2021
Section Cited
CCR
874119(a)
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87411 Personnel Requirement(a)Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision
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The licensee will ensure that each shift is fully staffed to accommodate the number of residents in care. The facility will submit a copy of the facility schedule every week by 5pm to the department for a month beginning on the the due date indictated.
Type B
06/29/2021
Section Cited
CCR
87625(a)(3)
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87625 Managed Incontinence(a)The licensee shall be permitted to accept or retain a resident who has a manageable bowel and/or bladder incontinence condition under the following circumstances:(3) Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence. This requirement is not met as evidenced by:Based on observation, Interviews, and record review, the licensee did not ensure that the facility is odor free. Which poses a potential Health, Safety, or Personal Rights risk to persons in care.
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The licensee will ensure that the facility is kept odor free, by conducting an inservice on incontinence care. The licensee will submit the sign in sheet to the department by 5pm on the due date indeicated.
Type B
06/29/2021
Section Cited
CCR
87211(a)(2)
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87211 Reporting Requirements
(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following:
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The licensee did not report an incident as required. The licensee will conduct an inservice on Reporting Requirements. The sign in sheet will be submitted to the department by 5pm on the due date indicated.
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(2) Occurrences, such as epidemic outbreaks, poisonings, catastrophes or major accidents which threaten the welfare, safety or health of residents, personnel or visitors, shall be reported within 24 hours either by telephone or facsimile to the licensing agency and to the local health officer when appropriate. This requirement is not met as evidenced by:
Based on observation, Interviews, and record review, the licensee did not ensure that reporting requirements were followed. Which poses a potential Health, Safety, or Personal Rights risk to persons in care.
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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.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javina GeorgeTELEPHONE: (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)
Page: 2 of 4
Control Number 18-AS-20200324194548
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 A
06/29/2021
Section Cited
CCR
87705(a)(2)
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87705 Care of Persons with Dementia
(a) This section applies to licensees who accept or retain residents diagnosed by a physician to have dementia. Mild cognitive impairment, as defined in Section 87101(m), is not considered to be dementia.
(2) Safety measures to address behaviors such as wandering, aggressive behavior and ingestion of toxic materials. This requirement is not met as evidenced by: The licensee did not ensure that R1 had staff available to provide special observation/night supervision, which resulted in a fall. This poses an immediate health, safety and personal rights risk to persons incare.
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The licensee agrees to have at minimum two staff working in the memory care unit during wake hours. The licensee will submit proof by 5pm on the due date indicated.
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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.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javina GeorgeTELEPHONE: (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)
Page: 3 of 4
Control Number 18-AS-20200324194548
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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Allegation #2 Facility does not have sufficient staff.
LPA conducted interviews, and file reviews. Based on the information provided from multiple sources. LPA was able to corroborate the allegation. Information provided stated that even before the Covid-19 pandemic staffing was an issue. There was constant overtime, where facility staff report that they were coming in early and staying late just to meet the needs of the facility. It was also reported that there were weeks where there was only one staff working in the memory care unit, when at minimum there should be two. The allegation of Facility does not have sufficient staff is SUBSTANTIATED.

Allegation#3 Facility failed to report incident to CCL.
Based on observation, file reviews, and interviews LPA was able to corroborate the allegation. R1 had two separate falls and the facility did not report the incidences via LIC624. There was an incident that occurred June of 2020, that resulted in staff being injured and it was not reported to the department. The allegation of Facility failed to report incident to CCL 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.

Based on the investigation conducted deficiencies were observed and cited according to California Code of Regulations, (Title 22, Division 6, Chapter will be cited and on the attached LIC9099D

An exit interview was conducted and a copy of this report, 9099D, and appeal rights was provided to Administrator Michael Garcia.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javina GeorgeTELEPHONE: (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)
Page: 4 of 4