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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331880730
Report Date: 12/16/2022
Date Signed: 12/27/2022 03:31:27 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
, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/16/2022 and conducted by Evaluator Amy Goldenberg
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20220816083338
FACILITY NAME:MORNING MIST HOMECAREFACILITY NUMBER:
331880730
ADMINISTRATOR:SANASINH, SIMMFACILITY TYPE:
740
ADDRESS:7902 NATOMA STTELEPHONE:
(949) 233-1643
CITY:EASTVALESTATE: CAZIP CODE:
92880
CAPACITY:6CENSUS: 6DATE:
12/16/2022
UNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Brooke Simm, AdministratorTIME COMPLETED:
11:45 AM
ALLEGATION(S):
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Staff are not repositioning resident
Staff are not providing medication to resident
INVESTIGATION FINDINGS:
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This unannounced visit by Amy Goldenberg, Licensing Program Analyst (LPA), This unannounced visit by Amy Goldenberg, Licensing Program Analyst (LPA), is being conducted to conclude this agency’s investigation into the complaint allegations mentioned above.

During the course of the investigation, interviews were conducted with staff and residents, a review of resident records, including medication orders, was completed and copies of pertinent documents were obtained. Investigation revealed the following: LPA learned that R1's mobility scooter was not working. Interview with R1 and S1 revealed that the scooter needed a new battery. R1 had initiated order of a new battery. R1 had a recliner in their room to use. S2 reports R1 would refuse to be moved often. During interview with R1, they denied that staff were not repositioning and admitted to refusal because of pain sometimes.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amy Goldenberg
LICENSING EVALUATOR SIGNATURE:

DATE: 12/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2022
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 2
Control Number 56-AS-20220816083338
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
, CA 92507
FACILITY NAME: MORNING MIST HOMECARE
FACILITY NUMBER: 331880730
VISIT DATE: 12/16/2022
NARRATIVE
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 R1 was requesting pain medication that they did not have an order for. R1 is able to make their own medical appointments. S1 reports that they provided assistance in making arrangements but there were issues with their insurance in regard to obtaining pain medication orders. R1 has their own telephone and are responsible for themselves. Four (4) of four (4) employees interviewed report repositioning R1 was difficult but was being completed.

Information obtained during this investigation is conflicting and therefore we have found the complaint allegation is unsubstantiated. Although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred as reported.

A copy of this report is being reviewed with and furnished to the facility representative.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amy Goldenberg
LICENSING EVALUATOR SIGNATURE:

DATE: 12/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2