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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331800081
Report Date: 03/02/2021
Date Signed: 03/02/2021 02:07:47 PM



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
08/25/2020 and conducted by Evaluator Deborah Mullen
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20200825091620
FACILITY NAME:BUSMAN RESIDENTIAL CARE LLCFACILITY NUMBER:
331800081
ADMINISTRATOR:READE, JOHNFACILITY TYPE:
740
ADDRESS:27892 BUSMAN ROADTELEPHONE:
(951) 541-5273
CITY:MURRIETASTATE: CAZIP CODE:
92563
CAPACITY:6CENSUS: 6DATE:
03/02/2021
UNANNOUNCEDTIME BEGAN:
01:38 PM
MET WITH:John Reade, LicenseeTIME COMPLETED:
01:39 PM
ALLEGATION(S):
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Due to a lack of supervision resident left the facility without staff’s knowledge.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Deborah Mullen delivered the findings of the above allegation to John Reade, Licensee. Due to Covid-19 restrictions the findings were delivered by telephone. During the investigation LPA interviewed both Licensees and other pertinent witnesses. LPA attempted to interview resident 1 (R1) but due to cognitive diagnosis LPA was unable to obtain a productive interview.

The allegation states that due to a lack of supervision resident left the facility without staff’s knowledge. On 8/17/2020 R1 exited the facility without staff’s knowledge. LPA interviewed the licensee who was the caregiver at that time. Licensee stated R1 was sitting at the dining room table eating lunch while she (the licensee) went to get another resident and assist him/her to the table. When licensee returned, R1 was not at the table and could not be found inside the home. Licensee contacted law enforcement for assistance in locating R1. R1 was found down the street a short time later by both law enforcement and the licensee. R1 had fallen and had scrapped his/her knee, consequently he/she was transported to the hospital to be assessed for any further injuries. R1 was cleared to return to the facility with no additional injuries noted.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 836-2784
LICENSING EVALUATOR NAME: Deborah MullenTELEPHONE: (951) 212-0616
LICENSING EVALUATOR SIGNATURE:

DATE: 03/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2021
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-20200825091620
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: BUSMAN RESIDENTIAL CARE LLC
FACILITY NUMBER: 331800081
VISIT DATE: 03/02/2021
NARRATIVE
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Based upon the investigation, the allegation that due to a lack of supervision resident left the facility without staff’s knowledge, is substantiated, and in accordance with Health and Safety Code, Title 22, Section 87705(c)(4), a citation is being issued. An exit interview was conducted whereby this report was reviewed with Mr. Reade. The report was emailed to Mr. Reade for his review and signature.
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 836-2784
LICENSING EVALUATOR NAME: Deborah MullenTELEPHONE: (951) 212-0616
LICENSING EVALUATOR SIGNATURE:

DATE: 03/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 18-AS-20200825091620
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: BUSMAN RESIDENTIAL CARE LLC
FACILITY NUMBER: 331800081
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/02/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/12/2021
Section Cited
CCR
87705(c)(4)
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Care of Persons with Dementia. Licensees who accept and retain residents with dementia shall be responsible for ensuring the following:There is an adequate number of direct care staff to support each resident’s physical, social, emotional, safety and health care needs as identified in his/her current appraisal.
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The licensee will complete training regarding the care of persons with dementia and wandering behaviors. Proof of completion must be submitted to Community Care Licensing by 3/12/21.
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This requirement was not being met as evidenced by: On 8/17/2020 R1 left the facility without staff’s knowledge. Due to R1’s cognitive diagnosis this posed an immediate health and safety risk to resident.
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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) 836-2784
LICENSING EVALUATOR NAME: Deborah MullenTELEPHONE: (951) 212-0616
LICENSING EVALUATOR SIGNATURE:

DATE: 03/02/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 3