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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604508
Report Date: 06/21/2022
Date Signed: 06/21/2022 04:06:55 PM


Document Has Been Signed on 06/21/2022 04:06 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507



FACILITY NAME:ESTANCIA SENIOR LIVINGFACILITY NUMBER:
374604508
ADMINISTRATOR:SMITH, LAWRENCEFACILITY TYPE:
740
ADDRESS:1735 SO MISSION ROADTELEPHONE:
(240) 595-6061
CITY:FALLBROOKSTATE: CAZIP CODE:
92028
CAPACITY:128CENSUS: 32DATE:
06/21/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Beatrice Bracamonte - Memory Care DirectorTIME COMPLETED:
04:15 PM
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On this date, Licensing Program Analyst (LPA) Crystal Colvin made an unannounced visit to the facility to investigate a complaint #18-AS-20220617091012. During today's inspection, LPA Colvin observed the following deficiencies, which was reviewed with Memory Care Director (MCD) Beatrice Bracamonte:
  • Personal Rights of Residents - LPA Colvin observed when in Resident's (R1) private bedroom that R1's wheelchair was nowhere to be found. LPA Colvin inquired with MCD and Executive Director Kimberly when they came to R1's room to meet LPA Colvin, and they additionally were unable to locate the wheelchair. MCD later inquired with memory care staff, and they informed MCD that the wheelchair was in the dining room, as R1 had gotten up and walked back to their room without it. Staff additionally stated that they accompanied R1 to their room for safety, but they left the wheelchair behind. LPA Colvin observed in R1's file that R1 needs an assistive device (such as walker or wheelchair) in order to ambulate. R1 is also documented to have had numerous falls since admission to the facility. Staff were aware of the need to accompany R1 due to R1 being a fall risk, but failed to ensure R1's assistive device was near to R1 (in bedroom) for R1 to be able to use and potentially prevent a fall. Deficiency cited.

  • Personal Rights of Residents - LPA Colvin reviewed R1's file and interviewed staff regarding a bruise and bump on R1's forehead, which was discovered on 6/15/22. Staff admitted that no medical attention was sought for R1. Staff stated that the reason was due to their lack of knowledge if the bruise was from a fall, as R1 is not a reliable historian. In further interviewing, staff admitted to LPA Colvin that if another resident were to present with a similar head injury, that the correct procedure would be to call 911, even if the injury was not from a fall. LPA Colvin inquired as to if this injury warrants medical attention, and staff confirmed that it does due to being a head injury. Staff failed to seek medical attention for R1 after observing a head injury. Deficiency cited.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Crystal ColvinTELEPHONE: (951) 204-0848
LICENSING EVALUATOR SIGNATURE:
DATE: 06/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/21/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: ESTANCIA SENIOR LIVING
FACILITY NUMBER: 374604508
VISIT DATE: 06/21/2022
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  • Criminal Record Clearance - LPA Colvin reviewed the facility's Staff Roster, which was obtained this morning from Guardian, and could not locate MCD on the roster. LPA Colvin requested for MCD to provide her with a copy of her Criminal Record Clearance Transfer Request. After a short time, MCD returned stating that the staff member who does the transfers told her that she has not gotten around to transferring MCD yet. MCD has been working at the facility for at least one month. Deficiency cited. Lack of transferring background clearance prior to staff working or being present at a facility results in a civil penalty of $100 a day for a maximum of five days for the facility's first offense (in 12 month period). since the facility has not had a prior deficiency for this and MCD has been working at the facility for at least five days, the facility is being cited the maximum $500 for 5 days of MCD working without their clearance being transferred.


Due to observations made by LPA Colvin, the facility was cited and deficiencies are noted on the LIC809D page(s). LPA Colvin conducted an exit interview with Memory Care Director (MCD) Beatrice Bracamonte, and a copy of this report, LIC809Ds, and appeal rights was provided.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Crystal ColvinTELEPHONE: (951) 204-0848
LICENSING EVALUATOR SIGNATURE:

DATE: 06/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2022
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 06/21/2022 04:06 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: ESTANCIA SENIOR LIVING
FACILITY NUMBER: 374604508

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/21/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/24/2022
Section Cited

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Additional Personal Rights of Residents in ...Facilities: (a) In addition to the rights listed ...residents in...facilities for the elderly shall have all of the following personal rights: (4) To care, supervision, and services that meet their individual needs... This requirement was not met as evidenced by:
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Based on observations and record review, the Licensee did not comply with the above regulation with at least one resident (R1). Staff stated knowledge of R1's wheelchair not being readily accessible to R1, who has a history of falls. This was an immediate safety risk to R1.
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Type A
06/24/2022
Section Cited

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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 was not met as evidenced by:
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Based on interviews, the Licensee did not comply with the above regulation with at least one resident (R1). LPA Colvin confirmed that R1 was observed by staff to have a bruise and bump on their forehead, but staff did not seek any medical services for R1. This was an immediate health risk to R1.
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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: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Crystal ColvinTELEPHONE: (951) 204-0848
LICENSING EVALUATOR SIGNATURE:
DATE: 06/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/21/2022
LIC809 (FAS) - (06/04)
Page: 3 of 4


Document Has Been Signed on 06/21/2022 04:06 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: ESTANCIA SENIOR LIVING
FACILITY NUMBER: 374604508

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/21/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/24/2022
Section Cited

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Criminal Record Clearance: (e) All individuals subject to a criminal record review...shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c)... This requirement was not met as evidenced by:
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Based on interview and record review, the Licensee did not comply with the above regulation with one staff member. LPA Colvin confirmed that Memory Care Director has not had their criminal background clearance trasnferred to the facility since their start date. This is an immediate safety risk to all residents.
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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: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Crystal ColvinTELEPHONE: (951) 204-0848
LICENSING EVALUATOR SIGNATURE:
DATE: 06/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/21/2022
LIC809 (FAS) - (06/04)
Page: 4 of 4