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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 366405715
Report Date: 11/09/2023
Date Signed: 11/09/2023 11:59:52 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 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
11/07/2023 and conducted by Evaluator Magda Malcore
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20231107154843
FACILITY NAME:L & S LIFECAREFACILITY NUMBER:
366405715
ADMINISTRATOR:TOLENTINO, LISAFACILITY TYPE:
740
ADDRESS:25141 PROSPECT AVENUETELEPHONE:
(909) 796-5184
CITY:LOMA LINDASTATE: CAZIP CODE:
92354
CAPACITY:6CENSUS: 6DATE:
11/09/2023
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Lisa Tolentino, AdministratorTIME COMPLETED:
11:30 AM
ALLEGATION(S):
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Resident eloped from facility due to lack of supervision
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Magda Malcore conducted an unannounced complaint visit to the facility. LPA met with Administrator, Lisa Tolentino, and discussed the purpose of the visit.
The investigation consisted of LPA observations, files review, and interviews with relevant parties.
Regarding the allegation, resident eloped from facility due to lack of supervision, Interview with Administrator reveals that she and staff #1 live at the facility and provide 24 hour care and supervision. The Administrator stated that during the night, when Resident #1 (R1) eloped from the facility, she and staff#1 were sleeping and did not hear the sound of the door alarm. LPA review of R1's medical assessment reveals, R1 has a cognitive condition and is not to leave the facility unsupervised.
Based on evidence obtained during the investigation, the allegation 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.
A deficiency has been cited during today’s visit. An exit interview was conducted where reports LIC9099 and LIC9099-D were discussed. Copies of the reports with appeal rights were provided to the Administrator at the conclusion of the visit.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Magda MalcoreTELEPHONE: 951-248-0316
LICENSING EVALUATOR SIGNATURE:

DATE: 11/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2023
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-20231107154843
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: L & S LIFECARE
FACILITY NUMBER: 366405715
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/09/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/10/2023
Section Cited
CCR
87705(c)(4)(A)
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87705(c)Licensees who accept...residents with dementia shall be responsible for ensuring...(4)There is an adequate number of direct care staff to support.(A)In addition...a facility with fewer than 16 residents shall have at least one night staff person awake..This requirement is not met as evidenced by:
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Licensee/administrator shall submit to the Licensing Agency a plan on preventative measures the facility will take to ensure night supervision for residents with wandering behaviors.
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Based on LPA observation and interviews, the licensee did not comply with the section cited above by night staff sleeping during the time resident eloped, which poses an immediate 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: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Magda MalcoreTELEPHONE: 951-248-0316
LICENSING EVALUATOR SIGNATURE:

DATE: 11/09/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2023
LIC9099 (FAS) - (06/04)
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