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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 366426751
Report Date: 11/12/2020
Date Signed: 11/24/2020 10:49:59 AM



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
06/23/2020 and conducted by Evaluator Pauline Beschorner
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20200623153119
FACILITY NAME:EVANS ELDERLY RESIDENTIAL CAREFACILITY NUMBER:
366426751
ADMINISTRATOR:EVANS, KELLYFACILITY TYPE:
740
ADDRESS:13947 CASTILLE ST.TELEPHONE:
(760) 261-4241
CITY:VICTORVILLESTATE: CAZIP CODE:
92392
CAPACITY:6CENSUS: 1DATE:
11/12/2020
UNANNOUNCEDTIME BEGAN:
11:49 AM
MET WITH:Kelly EvansTIME COMPLETED:
12:15 PM
ALLEGATION(S):
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Staff failed to provide resident's records to authorized representative
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Pauline Beschorner conducted conducted this investigation visit telephonically due to Covid-19 to conclude this agency’s investigation into the complaint allegations mentioned above. LPA met with Kelly Evans, Administrator/Licensee.

The investigation included interviews with Administrator, witnesses 1-2 (W1 and W2) and record review. The allegation states the facility staff failed to provide resident’s records to authorized representatives. Interviews revealed a letter was mailed to the Administrator on May 8, 2020 requesting records. There was not a response to the request and an additional letter was sent via Fed Ex and faxed on June 19, 2020. Both letters included a Durable Power of Attorney (DPOA) showing W1 being R1’s representative. In addition, there was not a response to the second request. Administrator claims that a DPOA was never received and interviews revealed that arrangements of care were made for R1 with W1 and the Administrator was aware that W1 was R1’s representative.

CONTINUED ON NEXT PAGE
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Pauline BeschornerTELEPHONE: (951) 897-7936
LICENSING EVALUATOR SIGNATURE:

DATE: 11/12/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/12/2020
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 3
Control Number 18-AS-20200623153119
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: EVANS ELDERLY RESIDENTIAL CARE
FACILITY NUMBER: 366426751
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/12/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/05/2020
Section Cited
CCR
87468.1(a)(9)
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87468.1(a)(9): 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 (9) To have communications to the licensee from their representatives answered promptly and appropriately. This requirement was not met as evidenced by:
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Administrator/Licensee provided documentation to residents authorized representative in August 2020. Administrator/Licensee will provide LPA with a copy of the mailing receipt no later than Monday 11/16/2020.
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Based on interviews and record review the licensee did not provide resident’s records to authorized representative when requested on 5/8/2020 and 6/19/2020 which poses 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.
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Pauline BeschornerTELEPHONE: (951) 897-7936
LICENSING EVALUATOR SIGNATURE:

DATE: 11/12/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/12/2020
LIC9099 (FAS) - (06/04)
Page: 3 of 3
Control Number 18-AS-20200623153119
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: EVANS ELDERLY RESIDENTIAL CARE
FACILITY NUMBER: 366426751
VISIT DATE: 11/12/2020
NARRATIVE
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CONTINUED

Based on LPA interviews conducted and a review of records, the preponderance of evidence standard has been met. Therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division & Chapter number 87468.1(a)(9) are being cited on the attached LIC 9099D.

An exit interview was conducted, and a copy of this report was reviewed, and appeal rights were provided to Administrator Kelly Evans, whose signature on this form confirm receipt of the above-mentioned documents.
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Pauline BeschornerTELEPHONE: (951) 897-7936
LICENSING EVALUATOR SIGNATURE:

DATE: 11/12/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/12/2020
LIC9099 (FAS) - (06/04)
Page: 2 of 3