374602001-5-23-2023-18-AS-MVAO-CU4QM8-20230726121703

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374602001
Report Date: 05/23/2023
Date Signed: 05/23/2023 11:15:56 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE 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
05/15/2023 and conducted by Evaluator Tricia Danielson

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20230515164007

FACILITY NAME:	SILVER TREE VILLA		FACILITY NUMBER:	374602001
ADMINISTRATOR:	MOHAMMAD ARABSHAHI		FACILITY TYPE:	740
ADDRESS:	1592 SILVER TREE LN		TELEPHONE:	(760) 739-8393
CITY:	ESCONDIDO	STATE: CA	ZIP CODE:	92026
CAPACITY:	6	CENSUS: 4	DATE:	05/23/2023
		UNANNOUNCED	TIME BEGAN:	09:50 AM
MET WITH:	Regina Abdelgahni, Caregiver Mohammad Arabshahi, Administrator		TIME COMPLETED:	11:30 AM

ALLEGATION(S):

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Staff did not follow resident's care plan
Staff did not provide an adequate amount of drinking water to residents

INVESTIGATION FINDINGS:

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Licenisng Program Analyst (LPA) Tricia Danielson arrived unannounced to the facility to initiate an investigation into the allegations listed above. LPA met with Caregiver Regina Abdelgahni and Licensee/Administrator Mohammad Arabshahi and explained the purpose of the visit.
During today's visit, LPA toured the facility, interviewed three (3) staff and four (4) residents. Regarding the allegation "Staff did not follow resident's care plan", it was alleged from January 2014 to February 2014, facility staff did not keep Resident #1's (R1's) pressure relief cushion inflated. LPA toured the facility and did not observe any current residents utilizing a pressure relief cushion. Interviews conducted with two (2) of four (4) current residents reported they are happy with the care staff provide. Interviews conducted with three (3) staff revealed all three (3) staff did not recall R1 ever living at the facility. The facility is not required to keep resident records longer than three (3) years therefore there were no 2014 records available for review.
Regarding the allegation "Staff did not provide and adequate amount of drinking water to residents", it was alleged that from January 2014 to February 2014 staff would only provide residents with less than a cup of water at every meal and residents were only provided about a third of a cup of water each. Interviews conducted with two (2) of four (4) (CONTINUED ON LIC9099-C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Jazmond D Harris	TELEPHONE: (951) 782-4807
LICENSING EVALUATOR NAME: Tricia Danielson	TELEPHONE: (951) 565-7254
LICENSING EVALUATOR SIGNATURE:	DATE: 05/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2023

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 18-AS-20230515164007

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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

FACILITY NAME: SILVER TREE VILLA	FACILITY NUMBER: 374602001
	VISIT DATE: 05/23/2023

NARRATIVE

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(CONTINUED FROM LIC9099)
current residents reported they are provided a full glass of water at every meal. LPA observed drinking vessels containing clear liquid in three (3) of four (4) resident rooms. Upon arrival to the facility, LPA observed one (1) resident sitting at the table finishing a meal and a drinking container was on the table 3/4 full of clear liquid. Although the allegations may have happened or are valid, there is no preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated.
An exit interview was conducted and a copy of this report along with LIC811- Confidential Names list was provided.

SUPERVISOR'S NAME: Jazmond D Harris	TELEPHONE: (951) 782-4807
LICENSING EVALUATOR NAME: Tricia Danielson	TELEPHONE: (951) 565-7254
LICENSING EVALUATOR SIGNATURE:	DATE: 05/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2023

LIC9099 (FAS) - (06/04)

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