366425270-6-24-2021-18-AS-JESL-C992DQ-20211129161844

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 366425270
Report Date: 06/24/2021
Date Signed: 06/24/2021 03:56:41 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
06/17/2021 and conducted by Evaluator Javina George

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20210617132726

FACILITY NAME:	ABRIA DEL CIELO		FACILITY NUMBER:	366425270
ADMINISTRATOR:	CRISELDA ESPIRITU SANTO		FACILITY TYPE:	740
ADDRESS:	1589 N. WATERMAN AVE		TELEPHONE:	(909) 884-4757
CITY:	SAN BERNARDINO	STATE: CA	ZIP CODE:	92404
CAPACITY:	240	CENSUS: 163	DATE:	06/24/2021
		UNANNOUNCED	TIME BEGAN:	01:16 PM
MET WITH:	Administrator MaCriselda Espiritu Santo		TIME COMPLETED:	02:55 PM

ALLEGATION(S):

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Facility has pests.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Javina George made an unannounced visit to commence an investigation and to deliver findings for the allegation mentioned above. LPA met with Administrator MaCriselda Espirtu Santo and explained the purpose of the visit.

The complaint was investigated by the department. The investigation consisted of a review of documentation, interviews and observation.

LPA George toured the facility while in Resident #1 (R1) room, LPA checked R1's bedding and observed the mattress in a plastic cover and the sheets were fresh and clean. LPA observed R1 to have several fresh bites located on their left thigh, calf and ankle, right leg, and underneath their arm. R1 stated that they had last gotten bit as recent and last seen bed bugs last night (6/23/21), as well as baby roaches in their bathroom. LPA did not observe any roaches as the bathroom had already been cleaned by housekeeping.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Joel Esquivel	TELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javina George	TELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:	DATE: 06/24/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2021

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 18-AS-20210617132726

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: 06/24/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 06/25/2021 Section Cited HSC 1569.269(a)(5)	1 2 3 4 5 6 7	ENUMERATED RIGHTS: SEVERABILITY Residents of residential care facilities for the elderly shall have all of the following rights: To be accorded safe, healthful, and comfortable accommodations, furnishings, and equipment. This regulation was not met as evidenced by: The facility has an on going infestation. This is an immediate Health and Safety risk to residents in care.	1 2 3 4 5 6 7	Licensee is to ensure the exterminator company takes control of the infestation and service is to continue to all pests (roaches, bed bugs and mice) are removed. Rooms treated104, 106 133, 143, 222) Submit receipts or contract to CCL by the due date.
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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 Esquivel	TELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javina George	TELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:	DATE: 06/24/2021

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2021

LIC9099 (FAS) - (06/04)

Page: 3 of 3

Control Number 18-AS-20210617132726

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: 06/24/2021

NARRATIVE

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During the facility tour LPA also observed a dead cockroach laying in the corner by the door downstairs in one of the staff office's. While touring the kitchen LPA also observed a total of 5 Combat bait traps underneath the sink, that were placed under the shelf that stores canned foods as well as underneath the counter.

Additionally, while conducting tours in resident bedrooms, LPA observed a mouse trap underneath the dresser in resident #2 (R2) room. R2 stated during an interview with LPA that they have seen little/small mice running around as recent as over the weekend, and that there is a cat running around upstairs as well, to help with mice. LPA inquired with Administrator about their being a cat, but denied that there was a cat inside of the facility, and that a few months ago there was been a cat outside as the resident's used to feed it.

Based on observation, interview and record review the allegation of Facility has pest 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.

An exit interview was conducted and a copy of this report and appeal rights was provided to Administrator MaCriselda Espiritu Santo.

SUPERVISOR'S NAME: Joel Esquivel	TELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javina George	TELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:	DATE: 06/24/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2021

LIC9099 (FAS) - (06/04)

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