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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 366425270
Report Date: 04/06/2023
Date Signed: 04/06/2023 01:13:26 PM

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
, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/30/2023 and conducted by Evaluator Anna Bueno
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20230330134902
FACILITY NAME:ABRIA DEL CIELOFACILITY NUMBER:
366425270
ADMINISTRATOR:CRISELDA ESPIRITU SANTOFACILITY TYPE:
740
ADDRESS:1589 N. WATERMAN AVETELEPHONE:
(909) 884-4757
CITY:SAN BERNARDINOSTATE: CAZIP CODE:
92404
CAPACITY:240CENSUS: DATE:
04/06/2023
UNANNOUNCEDTIME BEGAN:
09:02 AM
MET WITH:TIME COMPLETED:
01:15 PM
ALLEGATION(S):
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Staff do not ensure resident records are properly maintained.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Anna Bueno conducted an unannounced visit to the facility to initiate the complaint investigation and deliver findings on the above allegation. LPA met with administrator May Cabrera and licensee Edna Medrano who were informed of the purpose of today’s visit. The investigation consisted of interviews with relevant parties, observations of the facility, and review of relevant records.

The allegation is Staff do not ensure Resident 1 (R1) records are properly maintained. LPA observed resident records in the secured medication room. Interview with staff nurse (SN) confirmed that R1 is taking three insulin medications, one (M1) of which the unit dosage changes depending on R1’s blood sugar level. SN further explains that SN will administer the appropriate M1 dosage depending on R1’s blood sugar reading and that R1’s blood sugar is recorded daily but the medication administration record (MAR) only reflects that M1 was given by SN’s initial.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Anna BuenoTELEPHONE: 951-204-4307
LICENSING EVALUATOR SIGNATURE:

DATE: 04/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/06/2023
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
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
, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/30/2023 and conducted by Evaluator Anna Bueno
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20230330134902

FACILITY NAME:ABRIA DEL CIELOFACILITY NUMBER:
366425270
ADMINISTRATOR:CRISELDA ESPIRITU SANTOFACILITY TYPE:
740
ADDRESS:1589 N. WATERMAN AVETELEPHONE:
(909) 884-4757
CITY:SAN BERNARDINOSTATE: CAZIP CODE:
92404
CAPACITY:240CENSUS: DATE:
04/06/2023
UNANNOUNCEDTIME BEGAN:
09:02 AM
MET WITH:TIME COMPLETED:
01:15 PM
ALLEGATION(S):
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3
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9
Staff do not properly communicate with residents medical provider.
INVESTIGATION FINDINGS:
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13
Licensing Program Analyst (LPA) Anna Bueno conducted an unannounced visit to the facility to initiate the complaint investigation and deliver findings on the above allegation. LPA met with administrator May Cabrera and licensee Edna Medrano who were informed of the purpose of today’s visit. The investigation consisted of interviews with relevant parties, observations of the facility, and review of relevant records.

The allegation is Staff do not properly communicate with R1’s medical provider. Interview with R1 confirmed that they are on their way to a medical apointment. Interview with staff nurse (SN) confirmed that they send a copy of R1’s April 2023 blood sugar reading to their primary care physician (PCP). SN also showed LPA communication between SN and PCP’s office showing R1’s March 2023 blood sugar log and SN explained that PCP scheduled an appointment with R1 because of this communication. This allegation is therefore unsubstantiated.

A finding that the complaint is UNSUBSTANTIATED means that 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. An exit interview was conducted where this report was discussed and provided to May Cabrera.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Anna BuenoTELEPHONE: 951-204-4307
LICENSING EVALUATOR SIGNATURE:

DATE: 04/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/06/2023
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 4
Control Number 56-AS-20230330134902
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
, CA 92507
FACILITY NAME: ABRIA DEL CIELO
FACILITY NUMBER: 366425270
VISIT DATE: 04/06/2023
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. This poses a potential risk health and safety risk to residents in care.

Refer to LIC809-D for deficiency cited. An exit interview was conducted where this report, LIC809-D, and appeal rights were discussed with and provided to Administrator Cabrera.
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Anna BuenoTELEPHONE: 951-204-4307
LICENSING EVALUATOR SIGNATURE:

DATE: 04/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/06/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 56-AS-20230330134902
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
, CA 92507

FACILITY NAME: ABRIA DEL CIELO
FACILITY NUMBER: 366425270
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/06/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/20/2023
Section Cited
CCR
87465(a)6
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Incidental Medical and Dental Care
When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility
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Licensee shall conduct in-house training and update medication administration recording. Medication records must reflect appropriate dose administered for medications that have variable dose.
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This requirement was not met as evidenced by:
LPA observed R1's medication record does not reflect dosage administered for medication 1 (M1).
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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: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Anna BuenoTELEPHONE: 951-204-4307
LICENSING EVALUATOR SIGNATURE:

DATE: 04/06/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/06/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 4