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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 366413258
Report Date: 02/27/2020
Date Signed: 03/19/2021 04:28:24 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
01/09/2020 and conducted by Evaluator Natalie Gayoso
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20200109114013
FACILITY NAME:MISSION COMMONSFACILITY NUMBER:
366413258
ADMINISTRATOR:SPENCER, LORIFACILITY TYPE:
740
ADDRESS:10 TERRACINA BLVDTELEPHONE:
(909) 307-6251
CITY:REDLANDSSTATE: CAZIP CODE:
92373
CAPACITY:59CENSUS: 49DATE:
02/27/2020
UNANNOUNCEDTIME BEGAN:
01:50 PM
MET WITH:Marian Soriano - Wellness DirectorTIME COMPLETED:
04:40 PM
ALLEGATION(S):
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Staff did not respond to resident's call button.
INVESTIGATION FINDINGS:
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***THIS IS AN AMENDED REPORT TO CORRECT THE LIC 9099 DATED AND SIGNED ON 2/27/2020. ***
Licensing Program Analyst (LPA) Natalie Gayoso contacted the facility via telephone due to COVID-19 to deliver findings for the above allegation. LPA identified herself and spoke with Wellness Director Marian Soriano.
LPA requested and received facility file documents and conducted interviews with facility staff, Resident #1, and outside parties.The allegation indicates that staff did not respond to resident’s call button. LPA conducted interviews with staff #1-#3. Two (2) out Three (3) interviews with staff disclosed that when residents use call button, they finish their current duty before responding to the calls. Interviews with staff also revealed response times are high due to not enough staff on the floor. This poses a potential health and safety risk to the residents in care.
Based on LPA’s observations and interviews, which were conducted, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code
of Regulations, (Title 22, Division 6 & Chapter 8) is being cited on the attached LIC9099D.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Natalie GayosoTELEPHONE: (951) 290-1102
LICENSING EVALUATOR SIGNATURE:

DATE: 02/27/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2020
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 3
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
01/09/2020 and conducted by Evaluator Natalie Gayoso
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20200109114013

FACILITY NAME:MISSION COMMONSFACILITY NUMBER:
366413258
ADMINISTRATOR:SPENCER, LORIFACILITY TYPE:
740
ADDRESS:10 TERRACINA BLVDTELEPHONE:
(909) 307-6251
CITY:REDLANDSSTATE: CAZIP CODE:
92373
CAPACITY:59CENSUS: 49DATE:
02/27/2020
UNANNOUNCEDTIME BEGAN:
01:50 PM
MET WITH:Marian Soriano - Wellness DirectorTIME COMPLETED:
04:40 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not clean resident properly.
INVESTIGATION FINDINGS:
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13
Licensing Program Analyst (LPA) Natalie Gayoso conducted an unannounced visit. The purpose of this visit is to deliver the finding on the above allegations. LPA was greeted by Wellness Director Marian Soriano.

The investigation consisted of file reviews and interviews with relevant parties. The allegation indicates that staff did not clean resident properly. LPA conducted interviews with staff and resident (R1). Interview with R1 revealed resident is able to clean self and at times does not need assistance. 2 out of 2 interviews with staff disclosed that R1 is able to clean self at times and staff will check resident to see if properly clean once done. Staff stated that when unable to clean self, they assist R1 with cleaning.
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, therefore the allegation is UNSUBSTANTIATED at this time.

An exit interview was conducted and a copy of this report, 9099D, and appeal rights were provided to the Wellness Director Marian Soriano.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Natalie GayosoTELEPHONE: (951) 290-1102
LICENSING EVALUATOR SIGNATURE:

DATE: 02/27/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2020
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 3
Control Number 18-AS-20200109114013
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: MISSION COMMONS
FACILITY NUMBER: 366413258
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/27/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/28/2020
Section Cited
CCR
87411(a)
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Personnel Requirements: Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs....

The requirement was not met as evidenced by:
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The licensee agrees to conduct training to all staff on how to respond effectively to call buttons. Proof will be submitted to the Department by 2/28/20
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Interviews conducted with facility staff and LPA review of facility call button log, staff responded to call button 41 mins after call request
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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: Natalie GayosoTELEPHONE: (951) 290-1102
LICENSING EVALUATOR SIGNATURE:

DATE: 02/27/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2020
LIC9099 (FAS) - (06/04)
Page: 3 of 3