331880730-3-9-2023-56-AS-NBRN-CR8UNR-20230425154422

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 331880730
Report Date: 03/09/2023
Date Signed: 03/09/2023 03:32:47 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
03/03/2023 and conducted by Evaluator Amy Goldenberg

COMPLAINT CONTROL NUMBER: 56-AS-20230303154117

FACILITY NAME:	MORNING MIST HOMECARE		FACILITY NUMBER:	331880730
ADMINISTRATOR:	SANASINH, SIMM		FACILITY TYPE:	740
ADDRESS:	7902 NATOMA ST		TELEPHONE:	(949) 233-1643
CITY:	EASTVALE	STATE: CA	ZIP CODE:	92880
CAPACITY:	6	CENSUS: 5	DATE:	03/09/2023
		UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Brooke Simm, Administrator		TIME COMPLETED:	03:45 PM

ALLEGATION(S):

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-Staff are sleeping in residents rooms
-Resident's are required to use the bathroom outside of their room
-Staff use resident's bathroom

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Amy Goldenberg is conducting this initial 10 day visit for the purpose of initiating investigation into the above mentioned complaint allegations. LPA met with Licensee Brook Simm and disclosed the elements of the allegation. During this complaint investigation LPA toured the pertinent areas of the facility, reviewed a staffing schedule (LIC500), and interviewed caregivers S1 and S2. It is alleged that staff are using the closet in bedroom #1 to sleep, that staff are sleeping in bedroom #4 which a resident lives in and that occupants of bedroom #1 are not allowed to use the bathroom in that room as it is designated for staff. Investigation revealed the following information: This facility has around the clock awake staff. Review of LIC500 shows around the clock staffing. S1 and S2 denied living in the facility or sleeping in the facility. When asked S1 and S2 report they use the restroom near the front door designated for staff and visitors. LPA tour of the facility did not reveal any mattresses as alleged.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amy Goldenberg
LICENSING EVALUATOR SIGNATURE:	DATE: 03/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/09/2023

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 56-AS-20230303154117

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: 03/09/2023

NARRATIVE

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The closet in bedroom #1 is being used as storage. LPA observed storage of wheelchairs, commode and shower chairs. LPA did not observe any evidence that staff are sleeping in that space. Bedroom #1 is not occupied at this time by any residents.

We have found the complaint allegation is unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

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: 03/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/09/2023

LIC9099 (FAS) - (06/04)

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