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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331880541
Report Date: 12/20/2021
Date Signed: 12/20/2021 05:17:56 PM

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
12/14/2021 and conducted by Evaluator Javina George
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20211214124454
FACILITY NAME:ROLLING GREEN SENIOR CAREFACILITY NUMBER:
331880541
ADMINISTRATOR:OKORO, GERTRUDEFACILITY TYPE:
740
ADDRESS:42007 THOROUGHBRED LNTELEPHONE:
(951) 397-3369
CITY:MURRIETASTATE: CAZIP CODE:
92562
CAPACITY:6CENSUS: 3DATE:
12/20/2021
UNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Caregiver Traci BrownTIME COMPLETED:
05:30 PM
ALLEGATION(S):
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Medications are accessible to residents in care.
Residents are not receiving assistance with incontinence needs.
Staff do not respond to residents' call for assistance.
Staff are not assisting residents' with hygiene needs.
Facility does not provide meals of the quality and quantity to meet the needs of the residents.
Facility is not disposing of expired or abandoned medications.
Facility does not have adequate food supplies on hand.
Refrigerated foods are not stored properly


INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Javina George arrived at the facility unannounced to commence a complaint investigation as well as to deliver findings for the allegation(s) listed above. LPA was greeted and granted entry by Caregiver Traci Brown and explained the purpose of the visit and element of the allegation. The Administrator was unavailable to meet due to being out of the country.

Medications are accessible to residents in care.
At 12:43pm LPA observed the closet in the hallway that stores the residents medications to be unlocked. There is also a key hanging on the upper right-hand side on the outside of the door. One (1) of the three (3) residents are ambulatory and could access the medications. The allegation of Medications are accessible to residents in care is SUBSTANTIATED.

***Continued on 9099C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Javina George
LICENSING EVALUATOR SIGNATURE:

DATE: 12/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2021
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 6
Control Number 18-AS-20211214124454
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: ROLLING GREEN SENIOR CARE
FACILITY NUMBER: 331880541
VISIT DATE: 12/20/2021
NARRATIVE
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Residents are not receiving assistance with incontinence needs.
Based on interviews conducted the allegation of Residents are not receiving assistance with incontinence needs is SUBSTANTIATED. Information provided that at the time of LPAs visit resident had not been assisted with being changed for the day and it was 1:32pm. LPA inquired about what happens during the night and feedback provided was that staff do not come to the resident bedrooms.

Staff do not respond to residents' call for assistance.
LPA conducted interviews the information provided was that during the night, staff are not responding to the bells when they are rung. Due to only one staff being on during the evening, and per the facility program plan the night staff is expected to be awake. However, it was reported that that during the evening staff are not responding when assistance is requested. Additionally, it was reported that staff are not making their rounds during the evening. Therefore, the allegation of Staff do not respond to residents' call for assistance is SUBSTANTIATED.

Staff are not assisting residents' with hygiene needs.
Staff reported that the residents are given their baths in the morning after they wake up and if there was an “accident” depending on the severity an additional bath is given. LPA conducted interviews and reviewed resident files two (2) of the three (3) residents are not receiving any outside services such as home health or hospice. It is solely the facility staff responsibility to assist residents with their hygiene needs. It was reported that there are no showers being given, not even bed baths, just a wipe down, and when it does happen it isnot thoroughly. It is important to note that the two non-ambulatory residents do need two staff to assist them, however there is only one staff on during the shift at a time. Based on the information provided the allegation of Staff are not assisting residents' with hygiene needs is SUBSTANTIATED.

Facility does not provide meals of the quality and quantity to meet the needs of the residents. Information provided was that the food being served is old, rotten, and cold. LPA observed a container of Macaroni and Cheese that expired on December 4, 2021. During interviews conducted it was shared that the meals used to be complete and would be stored
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Javina George
LICENSING EVALUATOR SIGNATURE:

DATE: 12/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 18-AS-20211214124454
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: ROLLING GREEN SENIOR CARE
FACILITY NUMBER: 331880541
VISIT DATE: 12/20/2021
NARRATIVE
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in the freezer and taken out for mealtimes, however due to the residents not liking the precooked meals, the meals were no longer precooked. LPA was informed that chicken is rarely served, that it is normally sandwiches and overall terrible. The allegation of Facility does not provide meals of the quality and quantity to meet the needs of the residents is SUBSTANTIATED.

Facility does not have adequate food supplies on hand.
At the time of LPAs visit there was a full deep freezer, a cabinet and refrigerator with food in the garage as well as a refrigerator inside of the kitchen. The supply was more than the 2 day supply of perishable and a 7 day supply of nonperishable food items. The vegetables (green onion, tomato) were fresh. However, In addition, food is reported to have been brought from the food bank, as well as staff are bringing food in with them from the store or fast food restaurants to ensure that the residents are being served complete meals. An example provided of if dinner is supposed to be grilled chicken then it would be grilled chicken, with mashed potatoes, but no veggies to accompany the main course. The allegation of Facility does not have adequate food supplies on hand is SUBSTANTIATED.

Facility is not disposing of expired or abandoned medications.
LPA observed five (5) maroon containers sitting in the corner on the inside of the living room that contained medications of previous residents. LPA inquired as to what the plan is for the medications, staff on duty did not know. Additionally, there were not any medication destruction records available for review. The allegation of Facility is not disposing of expired or abandoned medications is SUBSTANTIATED.

Refrigerated foods are not stored properly.
At 12:35pm LPA toured the kitchen and observed a bowl of potato salad and a bowl of peaches left uncovered inside of the refrigerator. Based on observation the allegation of Refrigerated foods are not stored properly is SUBSTANTIATED. A finding that the complaint is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met.
An exit interview was conducted and a copy of this report, 9099D and appeal rights was provided to Caregiver Traci Brown.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Javina George
LICENSING EVALUATOR SIGNATURE:

DATE: 12/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 18-AS-20211214124454
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: ROLLING GREEN SENIOR CARE
FACILITY NUMBER: 331880541
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/20/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied: Appeal Not Submitted Timely
Type A
12/21/2021
Section Cited
CCR
87464(h)(2)
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Incidental Medical and Dental Care Services: Centrally stored medications shall be kept in a safe locked place that is not accessible to persons other than employees. LPA observed medication in staffs room to be accessible to clients and visitors. Based on observation this requirement is not met as evidenced by the closet being unlocked 1 out of 1 times. This poses an immediated health and safety risk to persons in care.
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Licensee agrees to provide training to all staff on the importance of keeping all medications locked at all times when not in use. POC is due by 5pm on the due date indicated.
Type B
01/04/2022
Section Cited
CCR
87555(b)(9)
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87555 General Food Service Requirements
(b) The following food service requirements shall apply: (9) Procedures which protect the safety, acceptability and nutritive values of food shall be observed in food storage, preparation and service. Based on observation the licensee did not properly store food on 2 out of 2 times. This poses a potential health and saftery risk to persons in care.
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Licensee agrees to conduct an inservice on proper food storage by the 5 pm on the due date indicated.
Request Denied: Appeal Not Submitted Timely
Type B
01/04/2022
Section Cited
CCR
87625(b)(2)
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87625 Managed Incontinence
(b) In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensee shall be responsible for the following: 2) Ensuring that incontinent residents are checked during those periods of time when they are known to be incontinent, including during the night. Based on interview the licensee did not ensure that resident was checked at least 1 out of 1 time., this poses a potential health, and saftery risk to persons in care.
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Licensee agrees to have staff document in resident logs that checks and incontinent care has been completed. The POC is due by 5pm on the due date indicated.
Request Denied: Appeal Not Submitted Timely
Type B
01/04/2022
Section Cited
HSC
1569(c)2
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Health and Safety Code section
(c) "Care and supervision" means the facility assumes responsibility for, or provides or promises to provide in the future, ongoing assistance with activities of daily living without which the resident’s physical health, mental health, safety, or welfare would be endangered. Assistance includes assistance with taking medications, money management, or personal care. Based on interviews the licensee did not assist resident when requested. This poses a potential health, safety or person rights risk to persons in care.
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The Licensee agrees to conduct an inservice on care and service, as well as review job descritption. Proof is to be submitted by 5pm on the due date indicated.
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: Joel Esquivel
LICENSING EVALUATOR NAME: Javina George
LICENSING EVALUATOR SIGNATURE:

DATE: 12/20/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 6
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
12/14/2021 and conducted by Evaluator Javina George
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20211214124454

FACILITY NAME:ROLLING GREEN SENIOR CAREFACILITY NUMBER:
331880541
ADMINISTRATOR:OKORO, GERTRUDEFACILITY TYPE:
740
ADDRESS:42007 THOROUGHBRED LNTELEPHONE:
(951) 397-3369
CITY:MURRIETASTATE: CAZIP CODE:
92562
CAPACITY:6CENSUS: 3DATE:
12/20/2021
UNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Caregiver Traci BrownTIME COMPLETED:
05:30 PM
ALLEGATION(S):
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Facility is dirty.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Javina George arrived at the facility unannounced to commence a complaint investigation as well as to deliver findings for the allegation(s) listed above. LPA was greeted and granted entry by Caregiver Traci Brown and explained the purpose of the visit and element of the allegation. The Administrator was unavailable to meet due to being out of the country.

Facility is dirty. Toured the interior and exterior of the facility. The facility was observed to be clean and clutter as well as odor free. The stove was observed to be clean with the usual wear and tear. LPA inquired with staff If there was a foul odor that came from the stove, in which staff denied. The stove was in use at the time of LPAs visit and no foul smelling odors were observed while staff prepared lunch and dinner. Therefore the allegation of Facility is dirty is UNSUBSTANTIATED.

An exit interview was conducted, and a copy of this report was provided to Caregiver Traci Brown.

Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Javina George
LICENSING EVALUATOR SIGNATURE:

DATE: 12/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 18-AS-20211214124454
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: ROLLING GREEN SENIOR CARE
FACILITY NUMBER: 331880541
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/20/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied: Appeal Not Submitted Timely
Type B
01/04/2022
Section Cited
CCR
87464(4)
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87464 Basic Services
(4) Personal assistance and care as needed by the resident and as indicated in the pre-admission appraisal, with those activities of daily living such as dressing, eating, bathing and assistance with taking prescribed medications, as specified in Section 87608, Postural Supports. This requirement is not met as evidenced by: Based on interview the licensee did not assistance 2 out of 2 residents with their hygiene needs, this poses a potential health safety and personal rights risk to persons in care.
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Licensee agrees to create a shower log. Proof of correction is to be be submitted to the department by 5pm on the due date indicated.
Type B
01/04/2022
Section Cited
CCR
87555(b)(26)
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87555 General Food Service Requirements: (b) The following food service requirements shall apply:(26) Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises. This requirement is not met as evidenced by: based on observation and interview the licensee did not ensure adequate food supplies on hand at minimum 2 out of 2 times. This poses a potential health, safety and personal rights risk to persons in care.
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Licensee agrees to submit receipts according to facility menu posted to ensure the residents are served complete meals. Proof of correction is to be submitted by 5pm on the due date indicated.
Type B
01/04/2022
Section Cited
CCR
87555(a)
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87555 General Food Service Requirements: (a) The total daily diet shall be of the quality and in the quantity necessary to meet the needs of the residents and shall meet the Recommended Dietary Allowances of the Food and Nutrition Board of the National Research Council. All food shall be selected, stored, prepared and served in a safe and healthful manner. This requirement is not met as evidenced by: Based on observation and interview the licensee did not ensure meals of quality and quantity are being served on 1 out of 1 time. This poses a potential health, safety or personal rights risk to persons in care.
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Licensee agrees to conduct an inservice on blood borne pathogens Proof of correction is to be submitted by 5pm on the due date indicated.
Type B
01/04/2022
Section Cited
CCR
87465(i)
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87465 Incidental Medical and Dental Care (i) Prescription medications which are not taken with the resident upon termination of services, not returned to the issuing pharmacy, nor retained in the facility as ordered by the resident’s physician and documented in the resident’s record nor disposed of according to the hospice’s established procedures or which are otherwise to be disposed of shall be destroyed in the facility by the facility administrator and one other adult who is not a resident. Both shall sign a record, to be retained for at least three years, which lists the following: This requrement is not met by Licensee having 5 containers full of medication the need to be destoryed. This poses a potential risk to persons in care.
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Licensee agrees to dispose of medication. Medication destruction record will be submitted to the dept by 5pm on the due date indicated.
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: Joel Esquivel
LICENSING EVALUATOR NAME: Javina George
LICENSING EVALUATOR SIGNATURE:

DATE: 12/20/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2021
LIC9099 (FAS) - (06/04)
Page: 6 of 6