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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331800173
Report Date: 02/25/2025
Date Signed: 02/25/2025 09:17:25 AM

Document Has Been Signed on 02/25/2025 09:17 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:MEGGINSON PLACE IIFACILITY NUMBER:
331800173
ADMINISTRATOR/
DIRECTOR:		RACELIS, JANETTEFACILITY TYPE:
740
ADDRESS:11330 LOMBARDY LANETELEPHONE:
(951) 363-8767
CITY:MORENO VALLEYSTATE: CAZIP CODE:
92557
CAPACITY: 6CENSUS: 5DATE:
02/25/2025
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:43 AM
MET WITH:Janette Vega Racelis, Administrator TIME VISIT/
INSPECTION COMPLETED:
09:25 AM
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Licensing Program Analyst (LPA) Javina George arrived on 02/25/25 for an unannounced case management visit to follow up on a substantiated allegation on a complaint investigation. LPA George met with Janette Vega Racelis, Administrator and reviewed the report.

On December 28, 2023, the Department concluded a complaint investigation regarding the following allegation: staff neglect contributed to a resident’s death.

The licensee was cited for California Code of Regulations § 87469(c)(3) – Advanced Directives and Requests Regarding Resuscitative Measures which states in part, “If a resident who has an advance directive and/or request regarding resuscitative measures form on file experiences a medical emergency, facility staff shall do one of the following: specifically for a terminally ill resident that is receiving hospice services and has completed an advance directive and/or request regarding resuscitative measures form pursuant to Health and Safety Code section 1569.73(c), and is experiencing a life-threatening emergency as displayed by symptoms of impending death that is… not directly related to the expected course of the resident’s terminal illness, the facility staff shall immediately telephone emergency response (9-1-1).”

At the time of the complaint visit on December 28, 2023, an immediate civil penalty of $500 was assessed and the licensee was informed that an additional civil penalty might be assessed based on Health and Safety § 1569.49.

The Department has concluded an analysis and has determined that a civil penalty is warranted for the death in accordance with Health and Safety Code Section § 1569.49. This is evidenced by the licensee’s failure to contact 911 or obtain emergency medical services when they observed an imminent threat to the health of the resident; and for failure to follow hospice nurse’s recommendation for medical intervention.
SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Javina George
LICENSING EVALUATOR SIGNATURE: DATE: 02/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/25/2025
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 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: MEGGINSON PLACE II
FACILITY NUMBER: 331800173
VISIT DATE: 02/25/2025
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Today February 25, 2025, the Department is issuing a civil penalty per Health and Safety Code § 1569.49 for a violation that the Department constitutes as contributing to the death, in the amount of $15,000. However, since an immediate civil penalty of $500 was previously assessed on December 28, 2023, the amount of the civil penalty assessed today will be $14,500.

A copy of the LIC 421D was given to Janette Vega Racelis, and originals were signed.

An exit interview was conducted. A copy of this report was issued. Appeal rights were provided. Janette Vega Raceli’s signature on this report acknowledges receipt of the appeal rights, found on page two of the LIC 421D.
SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Javina George
LICENSING EVALUATOR SIGNATURE:

DATE: 02/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/25/2025
LIC809 (FAS) - (06/04)
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