366425370-2-10-2023-56-AS-NBRN-CPFSXB-20230227131540

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 366425370
Report Date: 02/10/2023
Date Signed: 02/10/2023 03:47:52 PM

Unfounded

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
07/21/2022 and conducted by Evaluator Anna Bueno

PUBLIC

COMPLAINT CONTROL NUMBER: 56-AS-20220721160710

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: 5	DATE:	02/10/2023
		UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Regina Albudriz, lead		TIME COMPLETED:	03:50 PM

ALLEGATION(S):

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Resident was denied visitation.
Staff did not communicate with authorized representative about change of resident’s condition.

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPA) Anna Bueno and Michelle Echeverria conducted an unannounced visit to the facility to deliver findings on the above allegations. LPA identified themselves to Regina Albudriz, who was notified of the reason for today’s visit. The investigation included staff, witness, and resident interviews, and records review. Designee Janet Oliver arrived during today's visit and LPA Michelle Echeverria left the facility before the conclusion of today's visit.

Allegation 1: Resident was denied visitation. LPA reviewed visitor log that show the facility is open for visits. Interviews with staff reveal that the facility is following strict Covid-19 recommendations related to visitation, specifically for visitors testing positive for Covid-19. Witness interviewed stated that they gave the facility specific instructions regarding limiting visitors for Resident 1 (R1) and staff interviewed confirmed that the facility was following witness instructions. Records reviewed show that visiting hours were changed to accommodate visitor schedules. This allegation is unfounded.

Allegation 2: Staff did not communicate with authorized representative about change of resident’s condition. LPA reviewed text messages showing that the facility was in communication with R1's family. Witness interviews confirmed that R1 has a telecommunication device that facility staff use to communicate with witness. This

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Anna Bueno	TELEPHONE: 951-204-4307
LICENSING EVALUATOR SIGNATURE:	DATE: 02/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE:

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

Control Number 56-AS-20220721160710

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: 02/10/2023

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32	allegation is therefore unfounded. Based on the available information, we have found the complaint allegations are UNFOUNDED. A finding of unfounded means that the allegation is false, could not have happened and/or is without a reasonable basis. An exit interview was conducted where this report was discussed with, and a copy provided to Janet Oliver.

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Anna Bueno	TELEPHONE: 951-204-4307
LICENSING EVALUATOR SIGNATURE:	DATE: 02/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE:

LIC9099 (FAS) - (06/04)

Page: 2 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
07/21/2022 and conducted by Evaluator Anna Bueno

COMPLAINT CONTROL NUMBER: 56-AS-20220721160710

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: 5	DATE:	02/10/2023
		UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Regina Albidriz, lead		TIME COMPLETED:	03:50 PM

ALLEGATION(S):

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Resident sustained pressure injury while in care.

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPA) Anna Bueno and Michelle Echeverria conducted an unannounced visit to the facility to deliver findings on the above allegations. LPA identified themselves to Regina Albudriz, who was notified of the reason for today’s visit. The investigation included staff, witness, and resident interviews, and records review. Designee Janet Oliver arrived during today's visit and LPA Michelle Echeverria left the facility before the conclusion of today's visit.

It is alleged that Resident (R1) sustained pressure injury while in care. Per records reviewed, R1 arrived at the facility on 7/1/22. R1's LIC602, physician's report, signed on 7/1/2022 and medical notes from 6/24/2022 show that R1 has a stage 2 ulcer on their coccyx region and calluses on their feet, with a referral to outgoing home hospice. Interview with relevant parties confirm that R1 did not receive any outside health service. Records reviewed from 7/9/22 through 7/12/22 show that a bed sore had developed and was being treated. Medical records from 7/14/22 reveal that the wound was cleaned with no home health or hospice referral. Medical records dated 7/16/22 show that a wound evaluation was requested and hospice service were declined. Witness interviews reveal that R1 ultimately started hospice services on 7/21/2022. Interviews with staff revealed conflicting information on and documents reviewed show inconsistencies with R1 care charting on repositioning

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Anna Bueno	TELEPHONE: 951-204-4307
LICENSING EVALUATOR SIGNATURE:	DATE: 02/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE:

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 56-AS-20220721160710

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: 02/10/2023

NARRATIVE

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and toileting services.

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 was discussed, and a copy was provided to Janet Oliver at the conclusion of the visit.

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Anna Bueno	TELEPHONE: 951-204-4307
LICENSING EVALUATOR SIGNATURE:	DATE:

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE:

LIC9099 (FAS) - (06/04)

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