331800223-10-21-2021-18-AS-JESL-C9AT69-20211201132647

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 331800223
Report Date: 10/21/2021
Date Signed: 10/21/2021 01:55:38 PM

Unsubstantiated

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
02/21/2020 and conducted by Evaluator David Cuevas

COMPLAINT CONTROL NUMBER: 18-AS-20200221104723

FACILITY NAME:	YORKSHIRE VILLAGE		FACILITY NUMBER:	331800223
ADMINISTRATOR:	KNOOP, BENITA		FACILITY TYPE:	740
ADDRESS:	26933 CORNELL ST		TELEPHONE:	(951) 658-1068
CITY:	HEMET	STATE: CA	ZIP CODE:	92544
CAPACITY:	100	CENSUS: 75	DATE:	10/21/2021
		UNANNOUNCED	TIME BEGAN:	12:00 PM
MET WITH:	Executive Director, Teresa		TIME COMPLETED:	02:10 PM

ALLEGATION(S):

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Resident was left on the floor for an extended period of time
Resident fell and sustained an injury

INVESTIGATION FINDINGS:

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On 10/21/21 LPA Cuevas conducted an unannounced visit to the facility to follow up with complaint, control #18-AS-20200221104723.LPA was greeted by Executive Director, Teresa Mapilis who was informed of the purpose of visit.

During the investigation LPA Cuevas conducted: facility file review, resident record review, staff interviews, observations, and review of pertinent documents.

Allegation #1: Resident was left on the floor for an extended period.
Based on interviews conducted and documents reviewed by LPA, it was determined that that the evening of February 18, 2020 resident #1 (R1) was sent to Hospital as a result of staff observing R1 to be pale in appearance and not responding to their communication. Per staff statements and available records no falls were reported for R1 on 2/18/20. Furthermore, interviews provided suggest that R1's reason for being transported to hospital was a result of change of condition not unfitness fall.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: David Cuevas
LICENSING EVALUATOR SIGNATURE:	DATE: 10/21/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 18-AS-20200221104723

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: YORKSHIRE VILLAGE	FACILITY NUMBER: 331800223
	VISIT DATE: 10/21/2021

NARRATIVE

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Based on available information, there is not enough preponderance of evidence to determine that R1 was left in the floor for a long period of time, as such allegation is being UNSUBSTANTIATED, a findings that the allegation is UNSUBSTANTIATED means that that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the allegation occurred.

Allegation #2: Resident fell and sustained an injury
Based on interviews conducted and documents reviewed by LPA no falls were reported for R1 on 2/18/20 the day of hospitalization. Furthermore, interviews communicated that R1, who was wheelchair bound had exiting bruising and scrapes in both knees and hands prior to being sent out to hospital. Staff reports that scrapes and bruises were due to R1's constant banging on objects as a form of communication. Additionally, staff reports R1 to be tall in stature and to have had knees scraped and bruised as a result of R1 hitting his knees in the dining room table, when being agitated or anxious. Per staff, when such actions were observed first aid would be applied and behavioral interventions provided.

Based on available information, there is not enough preponderance of evidence to determine that R1 fell and sustained an injury, as such allegation is being UNSUBSTANTIATED, a findings that the allegation is UNSUBSTANTIATED means that that although the allegation allegation occurred..may have happened or is valid, there is not a preponderance of the evidence to prove that the

An exit interview was conducted with Executive Director, Teresa Mapilis were this report was reviewed and provided.

SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: David Cuevas
LICENSING EVALUATOR SIGNATURE:	DATE: 10/21/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2021

LIC9099 (FAS) - (06/04)

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