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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374604115
Report Date: 04/20/2023
Date Signed: 04/20/2023 10:53:45 AM

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
RIVERSIDE, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/13/2023 and conducted by Evaluator Stephanie Torres
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20230413101657
FACILITY NAME:COUNTRY ROSE ESTATE MEMORY CAREFACILITY NUMBER:
374604115
ADMINISTRATOR:PARAISO, CATHERINE TFACILITY TYPE:
740
ADDRESS:1255 ADVENTURE LNTELEPHONE:
(760) 738-9391
CITY:SAN MARCOSSTATE: CAZIP CODE:
92069
CAPACITY:15CENSUS: 9DATE:
04/20/2023
UNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Val Paraiso, AdministratorTIME COMPLETED:
11:00 AM
ALLEGATION(S):
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Lack of supervision resulted in resident eloping from facility and sustaining an injury
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Stephanie Torres, conducted an unannounced visit to the facility to start the investigation into the above allegation. The LPA met with Val Paraiso, Administrator, and informed him of the purpose of the visit.

The LPA conducted staff/resident interviews, reviewed records, and took copies of pertinent documentation. A report was received alleging Resident One (R1) left the facility unsupervised on April 11, 2023 and was later found on the same day with a cut to their hand. The Administrator was interviewed and corroborated the allegation; he reported R1 did leave the facility without staff knowledge and was found approximately forty minutes later. Per staff, a third party contractor was providing maintenance services at the time and may have not properly locked the one exit gate on the property. Staff interviews reported R1 appeared to have sustained a fall due to observing dirt on their clothing and a cut on their hand. Interviews revealed R1 is not able to safely leave the facility unsupervised. Therefore, based on interviews, this allegation is deemed SUBSTANTIATED. A finding that the complaint is substantiated means the allegation is valid because the preponderance of the
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Deborah Mullen
LICENSING EVALUATOR NAME: Stephanie Torres
LICENSING EVALUATOR SIGNATURE:

DATE: 04/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/20/2023
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-20230413101657
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: COUNTRY ROSE ESTATE MEMORY CARE
FACILITY NUMBER: 374604115
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/20/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/04/2023
Section Cited
CCR
87464(f)(1)
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BASIC SERVICES: (f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement was not met, as evidenced by: Based on interviews, the Licensee did not ensure R1 was supervised.
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The Administrator stated an automatic door lock will be installed on the one exit gate on the property.
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The Administrator was interviewed & corroborated the allegation; he reported R1 did leave the facility without staff knowledge & was found approximately 40 mins later. Staff interviews reported R1 appeared to have sustained a fall due to observing dirt on their clothing & a cut on their hand.
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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: Deborah Mullen
LICENSING EVALUATOR NAME: Stephanie Torres
LICENSING EVALUATOR SIGNATURE:

DATE: 04/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/20/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3
Control Number 18-AS-20230413101657
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: COUNTRY ROSE ESTATE MEMORY CARE
FACILITY NUMBER: 374604115
VISIT DATE: 04/20/2023
NARRATIVE
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evidence standard has been met. A citation will be issued.

An exit interview was conducted; this report was reviewed with the Administrator and a copy was provided, along with appeal rights.
SUPERVISORS NAME: Deborah Mullen
LICENSING EVALUATOR NAME: Stephanie Torres
LICENSING EVALUATOR SIGNATURE:

DATE: 04/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/20/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3