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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 366425270
Report Date: 07/12/2021
Date Signed: 07/12/2021 03:34:48 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
06/30/2021 and conducted by Evaluator Javina George
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20210630173210
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: 163DATE:
07/12/2021
UNANNOUNCEDTIME BEGAN:
02:28 PM
MET WITH:Administrator Macriselda Espiritu SantoTIME COMPLETED:
03:50 PM
ALLEGATION(S):
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Licensee did not notify the person responsible for the resident within seven days of the occurrence of an unexplained absence of resident.
INVESTIGATION FINDINGS:
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Licensing Program Analyst(LPA) Javina George arrived unannounced at the facility to commence a complaint investigation and to deliver findings for the allegation listed above. LPA met with Administrator Criselda and explained the purpose of the visit and discussed the elements of the allegations pertaining to the complaint.

LPA George conducted staff interviews and reviewed pertinent documentation. Through documentation review it was revealed that the facility did attempt to notify the responisble party of Resident #1 (R1) going awol on 5/25/21, from the facility via email on 5/27/21. However the email address was not correct, the sender staff #1 (S1) did not follow up to confirm within a timely manner that the responsible party was aware of R1s absence, which resulted in R1s responsible party being notified on 6/11/21, when the sender made additional contact. A missing person's report was filed with San Bernardino Police department. Based on interviews and record review the allegation of Licensee did not notify the person responsible for the resident within seven days of the occurrence of an unexplained absence of resident 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: 07/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/12/2021
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
Control Number 18-AS-20210630173210
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: ABRIA DEL CIELO
FACILITY NUMBER: 366425270
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/12/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/26/2021
Section Cited
CCR
87211(1)(D)
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87211 Reporting Requirements
(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. (D) Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident. This requirement is not met as evidenced by:
Based on observation, interview and record review the licensee did not follow reporting requirements 1 out of 1 times. This poses a potential health, safety or personal rights risk to persons in care.
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The licensee agrees to update the emergency contact information for R1, and have a reporting requirements training. Proof is to be submitted to the department 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: 07/12/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/12/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 18-AS-20210630173210
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: ABRIA DEL CIELO
FACILITY NUMBER: 366425270
VISIT DATE: 07/12/2021
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.

An exit interview was conducted and a copy of this report and appeal rights were provided to Administrator Macriselda Espiritu Santo.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javina GeorgeTELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:

DATE: 07/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/12/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 3