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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 366425370
Report Date: 08/23/2022
Date Signed: 08/23/2022 02:31:06 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
01/26/2022 and conducted by Evaluator Anna Bueno
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20220126143226
FACILITY NAME:ROSE VILLAFACILITY NUMBER:
366425370
ADMINISTRATOR:MANZOOR R. MASSEYFACILITY TYPE:
740
ADDRESS:11906 KINGSTON STREETTELEPHONE:
(909) 825-7673
CITY:GRAND TERRACESTATE: CAZIP CODE:
92313
CAPACITY:6CENSUS: 3DATE:
08/23/2022
UNANNOUNCEDTIME BEGAN:
11:24 AM
MET WITH:Manzoor Massey, LicenseeTIME COMPLETED:
02:35 PM
ALLEGATION(S):
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Facility has pests.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Anna Bueno conducted an unannounced visit to deliver findings on the complaint allegation: Facility has pests. LPA identified herself to staff Gina Albidruz, who was notified of the reason for today’s visit. Staff phoned licensee Manzoor Massey, who arrived shortly. The investigation included inspection of the facility, staff interviews, and review of facility records.

LPA Anna Bueno conducted multiple facility visits and observed pests in the kitchen area and in 1 of 5 resident bedrooms. Staff interviews also confirmed that the facility had a pest control treatment days prior to LPA's 6/6/2022 visit. The facility submitted pest treatment and inspection reports from a licensed pest control company prior to the delivery of the complaint finding.

Based on the above information th preponderance of the evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Refer to LIC 9099D for deficiency cited. An exit interview was conducted where this report, LIC 9099D, and appeal rights were provided Dr. Manzoor Massey.
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: 08/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2022
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 6
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
01/26/2022 and conducted by Evaluator Anna Bueno
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20220126143226

FACILITY NAME:ROSE VILLAFACILITY NUMBER:
366425370
ADMINISTRATOR:MANZOOR R. MASSEYFACILITY TYPE:
740
ADDRESS:11906 KINGSTON STREETTELEPHONE:
(909) 825-7673
CITY:GRAND TERRACESTATE: CAZIP CODE:
92313
CAPACITY:6CENSUS: 3DATE:
08/23/2022
UNANNOUNCEDTIME BEGAN:
11:24 AM
MET WITH:Manzoor Massey, LicenseeTIME COMPLETED:
02:35 PM
ALLEGATION(S):
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Resident meals do not consist of an appropriate variety of foods
Resident lost drastic amount of weight
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Anna Bueno conducted an unannounced visit to deliver findings on the above-mentioned complaint allegations. LPA identified herself to care provider Gina Albudriz, who was notified of the reason for today’s visit. The investigation consisted of resident and witness interviews and observations of the facility.

The allegations are resident meals do not consist of an appropriate variety of foods and
resident lost drastic amount of weight. Resident interview revealed that they wanted to lose weight and asked for their diet plan. Interview with witness stated that resident's care team agreed with the diet plan and witness would bring liquid food items and recipes to the facility. On a separate interview with both resident and witness together, both confirmed that weight loss was the goal of resident's diet plan and the weight lost only seems drastic because of the resident's previous body mass. Also, LPA observed during multiple visits witness bring in a variety of fresh and frozen food items from the resident's diet plan.

Based on the available information, we have found the complaint allegation is UNFOUNDED. A finding of unfounded means that the allegations were false, could not have happened and/or is without a reasonable basis. An exit interview was conducted where this report was discussed and a copy provided to Dr. Manzoor Massey.
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Anna BuenoTELEPHONE: 951-204-4307
LICENSING EVALUATOR SIGNATURE:

DATE: 08/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 5 of 6
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
01/26/2022 and conducted by Evaluator Anna Bueno
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20220126143226

FACILITY NAME:ROSE VILLAFACILITY NUMBER:
366425370
ADMINISTRATOR:MANZOOR R. MASSEYFACILITY TYPE:
740
ADDRESS:11906 KINGSTON STREETTELEPHONE:
(909) 825-7673
CITY:GRAND TERRACESTATE: CAZIP CODE:
92313
CAPACITY:6CENSUS: 3DATE:
08/23/2022
UNANNOUNCEDTIME BEGAN:
11:24 AM
MET WITH:Manzoor Massey, LicenseeTIME COMPLETED:
02:35 PM
ALLEGATION(S):
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Questionable death
Facility has insufficient emergency food supplies
Residents are left in soiled diapers for extended period of time
Facility toilet is in disrepair
Staff stole resident's medication
Staff did not have proper training to provide care and supervision to residents in care
Staff did not follow residents' care plan
Facility does not have planned activities for residents in care
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Anna Bueno conducted an unannounced visit to deliver findings on the above-mentioned complaint allegations. LPA identified herself to Gina Albidruz, who was notified of the reason for today’s visit. Staff phoned licensee Manzoor Massey, who arrived shortly. The investigation included observations of the facility, review of facility records, review of residents’ records, current and former staff interviews, and witness interviews.

Allegation 1: Questionable death. The complaint was received with a different resident name and LPA Bueno did not find any resident with this name that lived in the facility within the past 8 months. Interviews with staff revealed that there have been two resident deaths in the facility between December 2021 through January 2022. Resident 1 (R1) was admitted to the facility on 12/6/21. Interview with R1’s hospice nurse confirmed that R1 had been receiving hospice service before moving into this facility. Additionally, hospice nurse stated that during their facility visits they did not observe questionable behavior from staff and shared that the resident died naturally from their
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: 08/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2022
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 6
Control Number 18-AS-20220126143226
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: ROSE VILLA
FACILITY NUMBER: 366425370
VISIT DATE: 08/23/2022
NARRATIVE
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diagnosis. Resident 2 (R2) was admitted to the facility in 2018. Interviews with R2’s family stated that they did not suspect that the facility hastened the death of their family member and maintains that R2 died of natural causes. This allegation is therefore unsubstantiated.

Allegation 2: Facility has insufficient emergency food supplies. LPA Bueno visited the property multiple times and observed it to have sufficient food supplies and emergency food supplies. This allegation is unsubstantiated.

Allegation 3: Residents are left in soiled diapers for extended period of time. Resident interviews reveal that sometimes they may have to wait from 5 to 20 minutes to be changed because of the number of residents needing assistance at that time. Interviews with residents also revealed that residents think the wait time to be reasonable because of staff shortage. LPA Bueno observed that one staff working per shift. This allegation is therefore unsubstantiated.

Allegation 4: Facility toilet is in disrepair. LPA Bueno visited the facility multiple times and found the toilets to be working. Witness interviews revealed that one of three bathrooms was not working for a week, but they were given access to the other toilets and the broken toilet was fixed within the same week. This allegation is unsubstantiated.

Allegation 5: Staff stole resident's medication. Staff interviews reveal that they have not seen any staff take residents’ medications for any other purpose than administering it to residents. Witness interviews reveal that they noticed Resident 3’s (R3) as needed (PRN) pain medication intake increased, and they educated staff on how to assist R3 without having to give too many PRN pain pills in a day. LPA reviewed completed medication administration record (MAR) for centrally stored medication and PRN (as needed) for 5 residents. This allegation is therefore unsubstantiated.

Allegation 6: Staff did not have proper training to provide care and supervision to residents in care. Former staff interviews revealed that they received 11 hours of training, including hands-on training in three days before separating with the facility in less than a work week. Staff interviews also revealed that a full week training is completed within the first week of a newly hired staff. LPA observed dementia staff training binder and module and monthly staff meeting agenda covering This allegation is unsubstantiated.

SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Anna BuenoTELEPHONE: 951-204-4307
LICENSING EVALUATOR SIGNATURE:

DATE: 08/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 18-AS-20220126143226
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: ROSE VILLA
FACILITY NUMBER: 366425370
VISIT DATE: 08/23/2022
NARRATIVE
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Allegation 7: Staff did not follow residents’ care plan. Witness interviews revealed that staff are following care plan, specifically R3’s dietary care plan. Witnesses stated that the dietary plan was requested by R3 and was approved by their care team. This allegation is therefore unsubstantiated.

Allegation 8: Facility does not have planned activities for residents in care. LPA Bueno visited the facility multiple times and observed books, magazines, and puzzles available for residents and visitors. LPA observed one resident completing a puzzle in the living room during a visit. LPA also observed that all residents had their own electronic devices for personal entertainment. LPA viewed the daily social activity schedule. Staff interviews confirm that two former residents participate in some social activities with staff. This allegation is 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 Dr. Manzoor Massey at the conclusion of the visit.

SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Anna BuenoTELEPHONE: 951-204-4307
LICENSING EVALUATOR SIGNATURE:

DATE: 08/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 18-AS-20220126143226
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: ROSE VILLA
FACILITY NUMBER: 366425370
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/23/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/23/2022
Section Cited
CCR
87303(a)
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The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
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Licensee has provided the Department a correction plan from a previous citation. This deficiency has been satisfied prior to the delivery of the complaint findings.
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This requirement is not met as evidenced by:
Based on LPAs observation and records review, the licensee did not comply with the section cited above as LPAs observed live pests in the kitchen area which poses/posed a potential health, safety or personal rights risk to persons in care.
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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: 08/23/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2022
LIC9099 (FAS) - (06/04)
Page: 6 of 6