366425370-3-26-2024-56-AS-NBRN-D46V29-20240409160243

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 366425370
Report Date: 03/26/2024
Date Signed: 03/26/2024 02:55:01 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO ASC, 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
01/03/2023 and conducted by Evaluator Anna Fannell

PUBLIC

COMPLAINT CONTROL NUMBER: 56-AS-20230103155228

FACILITY NAME:	ROSE VILLA		FACILITY NUMBER:	366425370
ADMINISTRATOR:	MANZOOR R. MASSEY		FACILITY TYPE:	740
ADDRESS:	11906 KINGSTON STREET		TELEPHONE:	(909) 825-7673
CITY:	GRAND TERRACE	STATE: CA	ZIP CODE:	92313
CAPACITY:	6	CENSUS: 6	DATE:	03/26/2024
		UNANNOUNCED	TIME BEGAN:	02:28 PM
MET WITH:	Facility staff - Karina Chavares		TIME COMPLETED:	02:55 PM

ALLEGATION(S):

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Resident sustained a fracture while in care.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Anna Fannell conducted a subsequent visit to the facility to deliver findings on the above allegation. LPA met with care provider Karina Chaveres who was informed of the reason for today's visit. Chavares notified Licensee Mazoor Massey of LPA's presence and Massey arrived shortly. LPA conducted the initial complaint visit and investigation included interview with relevant parties and review of records.

It is alleged that Resident (R1) sustained a fracture while in care. On 1/2/2023, the Department received an incident report of R1 falling at the facility and being sent to a local hospital. The incident report further states that R1 sustained a broken leg and needed surgery. LPA reviewed American Medical Response (emergency services) records and records revealed that R1 leaned against a wall and gradually lowered themself to the ground while facility staff assisted R1 down. Review of LIC603A, Resident Appraisal, shows that R1 is able to walk without any assistance and R1 does not own any walking assistive devices. Physician’s report, LIC602, reviewed by LPA stated that R1 does not have motor impairment/paralysis and is ambulatory. Medical history noted that R1 is high risk for falls as of 01/02/2022. However, interview with Staff 1 (S1) revealed that R1

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Anna Fannell	TELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:	DATE: 03/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/26/2024

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 56-AS-20230103155228

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: ROSE VILLA	FACILITY NUMBER: 366425370
	VISIT DATE: 03/26/2024

NARRATIVE

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walks with a weak leg, appearing to drag their leg while ambulating. LPA Fannell review of hospital record shows that upon admission, R1 stated to attending physician that they were walking, tripped, and fell on their hip. Based on the above information, the allegation is therefore unsubstantiated.

Based on the available information, we have found the complaint allegations to be UNSUBSTANTIATED. A finding of unsubstantiated means that although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. An exit interview was conducted where this report (LIC 9099) was discussed, and a copy was provided to Manzoor Massey at the conclusion of the visit.

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Anna Fannell	TELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:	DATE: 03/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/26/2024

LIC9099 (FAS) - (06/04)

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