<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 366413258
Report Date: 10/28/2020
Date Signed: 09/09/2022 09:45:43 AM

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
03/11/2020 and conducted by Evaluator Naisha Kendrix
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20200311084232
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: 35DATE:
10/28/2020
UNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Interim Administrator, Marian Soriano TIME COMPLETED:
11:00 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Resident sustained multiple falls.
Resident sustained a fractured hip.
Facility staff refused to assist resident with their care needs
Facility staff did not respond to resident's call(s) for assistance
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA), Naisha Kendrix, identified herself to the Interim-Administrator, Marian Soriano and stated the reason for the call was to deliver the findings for the above allegations. This report, as of September 09, 2022, has been ammended by LPA, Stephanie Torres.

The department investigation included file review, interviews with staff/residents/witnesses, and collecting pertinent records. Based on evidence collected during the investigation, department staff determined there was corroborating evidence into the neglect/lack of supervision of Resident One (R1). Interviews and record review conducted by the department revealed staff found R1 on the floor multiple times. Staff indicated all falls sustained by R1 were unwitnessed. Wellness Director, Marian Soriano, indicated R1 started falling in 2019 and described the falls as being more like “slipping out of bed”. Ms. Soriano acknowledged R1 sustained multiple falls. As a result of the investigation, the allegation that R1 fell multiple times is SUBSTANTIATED.

Interviews and record review conducted by the Department revealed R1 sustained a fractured hip.
Substantiated
Estimated Days of Completion: 30
SUPERVISOR'S NAME: Deborah MullenTELEPHONE: (951) 248-0336
LICENSING EVALUATOR NAME: Stephanie TorresTELEPHONE: (951) 204-4307
LICENSING EVALUATOR SIGNATURE:

DATE: 09/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2022
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-20200311084232
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: 10/28/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/29/2020
Section Cited
CCR
87468.2(a)(4)
1
2
3
4
5
6
7
ADDITIONAL PERSONAL RIGHTS OF RESIDENTS IN PRIVATELY OPERATED FACILITIES: ...residents in privately operated RCFEs shall have all of the following personal rights: To care, supervision, & services that meet their individual needs & are delivered by staff that are sufficient in numbers,
1
2
3
4
5
6
7
The licensee will provide a statement of understanding addressing safe accommodations and fall prevention to residents who are a fall risk.
8
9
10
11
12
13
14
qualifications, & competency to meet their needs. This requirement wasn't met as evidenced by, based on interviews, the Licensee didn't ensure R1's needs were met. Due to lack of supervision R1 fell multiple times. This posed an immediate Health & Safety risk to residents in care.
8
9
10
11
12
13
14
Type A
10/29/2020
Section Cited
CCR
87411(a)
1
2
3
4
5
6
7
PERSONNEL REQUIREMENTS-GENERAL (a) Facility personnel shall at all times be sufficient in numbers, & competent to provide the services necessary to meet resident needs...This requirement was not met as evidenced by: Based on interviews & records, the licensee did not ensure R1's needs were
1
2
3
4
5
6
7
The licensee will conduct an in-service training to address following the resident's care plan and providing necessary supervision.
8
9
10
11
12
13
14
 met. Due to lack of supervision, R1 sustained a left hip fracture. This posed an immediate Health & Safety risk to residents in care. An Immediate Civil Penalty of $500 is being assessed. The licensee was also informed that a civil penalty may be assessed based on Health & Safety Code 1569.49(f).
8
9
10
11
12
13
14
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: Deborah MullenTELEPHONE: (951) 248-0336
LICENSING EVALUATOR NAME: Stephanie TorresTELEPHONE: (951) 204-4307
LICENSING EVALUATOR SIGNATURE:

DATE: 09/09/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 18-AS-20200311084232
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: 10/28/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/29/2020
Section Cited
CCR
87464(f)(1)
1
2
3
4
5
6
7
BASIC SERVICES: Basic services shall at a minimum include: Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement was not met as evidenced by: Based on interviews,
1
2
3
4
5
6
7
Licensee will ensure the basic services are provided to residents in care by documenting what and when care needs are provided to residents. licensee will provide a statement of understanding to CCL
8
9
10
11
12
13
14
the Licensee did not ensure R1 received care. Interviews revealed staff did not change R1's diaper and, rather placed 2 to 3 diapers on R1 so they didn't have to change the resident. This posed an immediate personal rights violation to the residents in care.
8
9
10
11
12
13
14
Type A
10/29/2020
Section Cited
CCR
87464(f)(4)
1
2
3
4
5
6
7
BASIC SERVICES(f) Basic services shall at a minimum include:(4) Personal assistance & care as needed by the resident & as indicated in the pre-admission appraisal, with those activities of daily living such as dressing, eating, bathing... This requirement wasn't met as evidence by: Based on interviews the
1
2
3
4
5
6
7
The licensee will conduct an
in-service training on how to meet the residents care needs as prescribed in the resident's care plan and provide a sign in sheet from the training.
8
9
10
11
12
13
14
 Licensee didn't ensure basic services were provided to R1. Interviews revealed R1 had requested assistance from staff with toileting and that R1 was not assisted by staff from 4PM - 9PM while R1's sitter was present. This posed an immediate personal rights violation to residents in care.
8
9
10
11
12
13
14
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: Deborah MullenTELEPHONE: (951) 248-0336
LICENSING EVALUATOR NAME: Stephanie TorresTELEPHONE: (951) 204-4307
LICENSING EVALUATOR SIGNATURE:

DATE: 09/09/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 18-AS-20200311084232
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
VISIT DATE: 10/28/2020
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Medical records state R1 was admitted to the hospital on October 25, 2019 and diagnosed with a left hip fracture. The staff at the facility did not know any information as to when or how R1 sustained the fractured hip, as all falls were unwitnessed. As a result of the investigation, the allegation that R1 sustained a left hip fracture is SUBSTANTIATED.

Interviews also revealed staff failed to assist R1 in changing, toileting or hygiene needs, per the needs and service plan dated 1/17/20. It was revealed that staff did not change R1's diaper and placed two to three diapers on R1 so they did not have to change the resident. Therefore, based on interviews, this allegation is deemed SUBSTANTIATED.

In addition, interviews revealed R1 has requested assistance from staff with toileting. Interviews revealed R1 was not assisted by facility staff from 4PM to 9PM while R1's sitter was present. Therefore, this allegation is deemed SUBSTANTIATED.

A finding that the complaint is substantiated means that the allegations are valid because the preponderance of the evidence standard has been met. An Immediate Civil Penalty of $500 is being assessed. The licensee was also informed that a civil penalty may be assessed based on Health and Safety Code 1569.49(f).

An exit interview was conducted with Soriano; this report was reviewed and a copy provided, along with LIC 811, LIC 421IM and Appeal Rights.
SUPERVISOR'S NAME: Deborah MullenTELEPHONE: (951) 248-0336
LICENSING EVALUATOR NAME: Stephanie TorresTELEPHONE: (951) 204-4307
LICENSING EVALUATOR SIGNATURE:

DATE: 09/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 4