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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 366426555
Report Date: 04/06/2022
Date Signed: 04/06/2022 04:41:17 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
09/21/2021 and conducted by Evaluator Stephanie Williams
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20210921132836
FACILITY NAME:APPEARANCE QUALITY HOMEFACILITY NUMBER:
366426555
ADMINISTRATOR:RILEY, RACHELFACILITY TYPE:
740
ADDRESS:10752 OAKWOOD AVE.TELEPHONE:
(760) 956-2800
CITY:HESPERIASTATE: CAZIP CODE:
92345
CAPACITY:6CENSUS: 3DATE:
04/06/2022
UNANNOUNCEDTIME BEGAN:
01:40 PM
MET WITH:Blanca GonzalezTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Facility staff did not seek timely medical attention for resident
Facility staff did not report injuries to Department in a timely manner
INVESTIGATION FINDINGS:
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Licensing Program Analyst's (LPA's) Stephanie Williams and Rayshaun Nickolas made an unannounced visit to the facility in order to initiate a complaint investigation into the above allegations. LPA's Williams and Nickolas identified themselves to Caregiver, Blanca Gonzalez, who was also informed of the purpose of the visit. LPA Williams spoke with the Administrator, Rachel Riley, over the phone. The investigation consisted of direct observations, records review, and interviews with staff and residents.

In regard to allegation #1, Department staff reviewed R1’s medical records. The medical records revealed that on 2/19/2018, R1 was seen in the emergency room for a laceration to the head as a result from an accident at the facility. The medical records further indicate that facility staff did not retrieve timely medical attention for R1 on the night that the injury was sustained on 2/18/2018. Department staff interviewed S1 regarding S1’s medical training. S1 stated that a patient with obvious head trauma would need to undergo a CT scan. Department staff then asked S1 why R1 was not provided medical care after obvious head trauma, to which S1 responded that, R1 is very independent. Furthermore, facility staff could not produce documentation showing that R1 received timely medical attention after sustaining head trauma on 2/18/2018.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Stephanie Williams
LICENSING EVALUATOR SIGNATURE:

DATE: 04/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/06/2022
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 5
Control Number 18-AS-20210921132836
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: APPEARANCE QUALITY HOME
FACILITY NUMBER: 366426555
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/06/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/07/2022
Section Cited
CCR
87468.1(a)(16)
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87468.1- Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (16) To receive or reject medical care or other services. This requirement has not been met as evidenced by:
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The Licensee shall conduct training on Regulation 87468.1 for all staff and send proof to the Department by POC date.
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Based on interviews, the Licensee did not seek timely medical attention for R1. This is a immediate health and safety risk to resident's in care.
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Type B
04/13/2022
Section Cited
CCR
87211(a)(1)(B)
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87211 - Reporting Requirements
(a) Each licensee shall furnish to the licensing agency such reports as the Department may require... (1)... (B) Any serious injury as determined by the attending physician and occurring while the resident is under facility supervision. This requirement has not been met as evidenced by:
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The Licensee shall conduct training on Regulation 87211(a)(1)(B) for all staff and send proof to the Department by POC date.
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Based on interviews and observations, the Licensee did not ensure that serious injuries were reported to the Department in a timely manner. This is a potential health and safety risk to resident's 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.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Stephanie Williams
LICENSING EVALUATOR SIGNATURE:

DATE: 04/04/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/04/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 18-AS-20210921132836
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: APPEARANCE QUALITY HOME
FACILITY NUMBER: 366426555
VISIT DATE: 04/06/2022
NARRATIVE
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In regard to allegation #2, Department staff interviewed S1, who stated that the facility has had several residents who have experienced a fall while residing in the facility. S1 admitted that the falls, which resulted in injuries, were not reported to the Department because the residents were on hospice. LPA Williams reviewed the Department’s records which showed that the facility sent several incident reports to the Department from 2017- 2019; however, the last incident report which was recorded by the Department from the facility was on 4/10/2019. Furthermore, LPA Williams retrieved an incident report dated 3/7/2021 while visiting the facility, which noted that R1 had been admitted to the hospital for altered mental capacity and lethargy. LPA Williams did not observe the incident report that logged in the Department’s records. Department staff interviewed S1 regarding the incident report dated 3/7/2021 and questioned why the incident report did not include the several injuries that were noted in R1’s medical records. S1 stated that it may have been an oversight on S1’s part. In addition to the incident report dated 3/7/2021 not being complete, it was also not recorded within the Department’s time frame for reporting requirements.

Based on the information and interviews gathered the above allegations is SUBSTANTIATED. A finding that the complaint is SUBSTANTIATED means that the allegation(s) is valid because the preponderance of the evidence standard has been met. Please see LIC 9099D for deficiencies cited.

An exit interview was conducted where this report (LIC 9099) was discussed and a copy was provided to Gonzalez at the conclusion of the visit.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Stephanie Williams
LICENSING EVALUATOR SIGNATURE:

DATE: 04/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/06/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 5
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
09/21/2021 and conducted by Evaluator Stephanie Williams
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20210921132836

FACILITY NAME:APPEARANCE QUALITY HOMEFACILITY NUMBER:
366426555
ADMINISTRATOR:RILEY, RACHELFACILITY TYPE:
740
ADDRESS:10752 OAKWOOD AVE.TELEPHONE:
(760) 956-2800
CITY:HESPERIASTATE: CAZIP CODE:
92345
CAPACITY:6CENSUS: 3DATE:
04/06/2022
UNANNOUNCEDTIME BEGAN:
01:40 PM
MET WITH:Blanca GonzlezTIME COMPLETED:
02:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Physical abuse by facility staff members resulting in resident sustaining serious injuries
INVESTIGATION FINDINGS:
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2
3
4
5
6
7
8
9
10
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13
Licensing Program Analyst's (LPA's) Stephanie Williams and Rayshaun Nickolas made an unannounced visit to the facility in order to initiate a complaint investigation into the above allegations. LPA's Williams and Nickolas identified themselves to Caregiver, Blanca Gonzalez, who was also informed of the purpose of the visit. LPA Williams spoke with the Administrator, Rachel Riley, over the phone. The investigation consisted of direct observations, records review, and interviews with staff and residents.

Department staff received several photos of current and former residents of the facility in which it appeared that those residents sustained injuries from an unknown origin. Department staff interviewed Witness #1 (W1), who claimed that Staff #1 (S1) and Staff #2 (S2) are physically abusive to residents in their care. Resident #1 (R1) had also indicated to Department staff that S2 had been physically abusive towards R1 on at least one occurrence. Department staff interviewed S1 and S2 who both denied being physically abusive to the residents in care. Staff #3 (S3) was also interviewed and denied having any knowledge of physical abuse by S1 and S2 towards the residents in care. Department staff also interviewed Resident #3 (R3)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Stephanie Williams
LICENSING EVALUATOR SIGNATURE:

DATE: 04/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/06/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 18-AS-20210921132836
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: APPEARANCE QUALITY HOME
FACILITY NUMBER: 366426555
VISIT DATE: 04/06/2022
NARRATIVE
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(R3) who denied being physically abused by facility staff members. An attempt to interview Resident #4 (R4) was made by Department staff; however, R4 was unable to make a statement. Department staff was unable to interview R2 as a result of R2’s passing prior to the investigation.

Furthermore, another witness, Witness #2 (W2), stated that they observed injuries on R2 during a visit to the facility. W2 stated they questioned S1 and S2 of R2’s injuries, to which S1 stated that R2 experienced a fall. S1 was shown the photos of several residents with various injuries. S1 initially stated that Resident #2 (R2) had sustained the injuries as a result from a recent vaccination. However, S1 then changed their story and stated that R2 experienced a fall while at the facility. S2 and S3 both denied that R2 experienced a fall while residing in the facility. At the time of closure of this investigation, there is insufficient evidence to prove or disprove that the injuries to the residents were a result of physical abuse caused by staff members. Therefore, the allegation is unsubstantiated.

Based on evidence obtained during the investigation, LPA has determined that the above allegation is UNSUBSTANTIATED; meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur.

An exit interview was conducted where this report (LIC 9099) was discussed and a copy was provided to Gonzalez at the conclusion of the visit.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Stephanie Williams
LICENSING EVALUATOR SIGNATURE:

DATE: 04/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/06/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 5