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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374603665
Report Date: 05/26/2022
Date Signed: 05/26/2022 11:12:30 AM

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
RIVERSIDE, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/20/2022 and conducted by Evaluator Tricia Danielson
COMPLAINT CONTROL NUMBER: 18-AS-20220520153932
FACILITY NAME:DEVON PLACE HOME CAREFACILITY NUMBER:
374603665
ADMINISTRATOR:MARK LOOFACILITY TYPE:
740
ADDRESS:1814 DEVON PLACETELEPHONE:
(760) 941-1818
CITY:VISTASTATE: CAZIP CODE:
92084
CAPACITY:6CENSUS: 6DATE:
05/26/2022
UNANNOUNCEDTIME BEGAN:
08:55 AM
MET WITH:Maria Zavala, CaregiverTIME COMPLETED:
11:00 AM
ALLEGATION(S):
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Facility temperature was too low.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Tricia Danielson arrived unannounced to the facility to initiate an investigation into the allegation listed above. LPA met with Caregivers Maria Zavala and Lourdes Dols and explained the purpose of the visit. Zavala contacted Administrator Mark Loo and Licensee Sherry Rafols via telephone to notify them of LPA's presence in the facility. LPA spoke with both of them regarding today's visit. Permission was granted for Zavala to receive and sign for LPA's report of today's visit.
Regarding the allegation "Facility temperature was too low", it was alleged that the facility maintained the indoor temperature at a level so low it caused a resident to shiver. The investigation revealed that room temperatures were measured at: Living room 73.5 degrees Fahrenheit, Room #1 77.1 degrees Fahrenheit, Room #2 74.4 degrees Farenheit, Room #3 74.1 degrees Fahrenheit, and Room #4 74.1 degrees Farenheit. It should be noted that in Room #3, Resident #3 (R3) had voluntarily cracked their bedroom window open and Resident #4 (R4) was voluntarily running a fan in their room. Interviews conducted with five (5) of six (6) residents revealed no complaints regarding the facility being maintained at a temperature too low. This agency has investigated the complaint alleging "Facility temperature was too low". We have (CONTINUED ON LIC 9099C)
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Deborah MullenTELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Tricia DanielsonTELEPHONE: (951) 565-7254
LICENSING EVALUATOR SIGNATURE:

DATE: 05/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2022
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-20220520153932
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: DEVON PLACE HOME CARE
FACILITY NUMBER: 374603665
VISIT DATE: 05/26/2022
NARRATIVE
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(CONTINUED FROM LIC 9099)
found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. An exit interview was conducted and a copy of this report was provided along with LIC 811- Confidential Names List.
SUPERVISOR'S NAME: Deborah MullenTELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Tricia DanielsonTELEPHONE: (951) 565-7254
LICENSING EVALUATOR SIGNATURE:

DATE: 05/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2022
LIC9099 (FAS) - (06/04)
Page: 2 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
RIVERSIDE, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/20/2022 and conducted by Evaluator Tricia Danielson
COMPLAINT CONTROL NUMBER: 18-AS-20220520153932

FACILITY NAME:DEVON PLACE HOME CAREFACILITY NUMBER:
374603665
ADMINISTRATOR:MARK LOOFACILITY TYPE:
740
ADDRESS:1814 DEVON PLACETELEPHONE:
(760) 941-1818
CITY:VISTASTATE: CAZIP CODE:
92084
CAPACITY:6CENSUS: 6DATE:
05/26/2022
UNANNOUNCEDTIME BEGAN:
08:55 AM
MET WITH:Maria Zavala, CaregiverTIME COMPLETED:
11:00 AM
ALLEGATION(S):
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Facility kitchen is dirty.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Tricia Danielson arrived unannounced to the facility to initiate an investigation into the allegation listed above. LPA met with Caregivers Maria Zavala and Lourdes Dols and explained the purpose of the visit. Zavala contacted Administrator Mark Loo and Licensee Sherry Rafols via telephone to notify them of LPA's presence in the facility. LPA spoke with both of them regarding today's visit. Permission was granted for Zavala to receive and sign for LPA's report of today's visit.
Regarding the allegation "Facility kitchen is dirty", it was alleged that the refrigerator top inner shelving was dirty and had mold on the surfaces. During today's investigation, LPA observed dirty shelving in the refrigerator as well as areas of mold on the inner refrigerator door. LPA also observed a long light brownish colored hair on the left inner bottom portion of the lower shelf. The vegetable drawers were also observed to be dirty and moldly. There was brown colored staining on the outer area of the lower right condiment shelf. LPA also observed dust and grime on the top of the refrigerator doors. Additionally, the wall areas behind and next to the stove were splashed with a brown greasy substance. Based on LPA's (CONTINUED ON LIC 9099- C)
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Deborah MullenTELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Tricia DanielsonTELEPHONE: (951) 565-7254
LICENSING EVALUATOR SIGNATURE:

DATE: 05/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2022
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 5
Control Number 18-AS-20220520153932
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: DEVON PLACE HOME CARE
FACILITY NUMBER: 374603665
VISIT DATE: 05/26/2022
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(CONTINUED FROM LIC 9099-A)
observations, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code Of Regulations, Title 22, Division 6, Chapter 8 are being cited on the attached LIC 9099 D.

An exit interview was conducted and a copy of this report was provided along with Appeal Rights.
SUPERVISOR'S NAME: Deborah MullenTELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Tricia DanielsonTELEPHONE: (951) 565-7254
LICENSING EVALUATOR SIGNATURE:

DATE: 05/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 18-AS-20220520153932
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: DEVON PLACE HOME CARE
FACILITY NUMBER: 374603665
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/26/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/09/2022
Section Cited
CCR
87303(a)
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Maintenance and Operation- (a) 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. This requirement was not met as evidenced by:
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The facility will clean the kitchen and refrigerator to remove all evidence of mold, grime, food staining, and hair and submit proof to CCL by POC due date of 6/9/2022.
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The Licensee did not ensure the facility kitchen and refrigerator were maintained with cleanliness. Based on LPA observations, the kitchen and refrigerator were observed to have grime, mold, food staining, and hair.
This poses a potential health, safety, and personal rights risks to residents 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: Deborah MullenTELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Tricia DanielsonTELEPHONE: (951) 565-7254
LICENSING EVALUATOR SIGNATURE:

DATE: 05/26/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 5