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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331880756
Report Date: 02/06/2023
Date Signed: 02/06/2023 10:17:22 AM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 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
01/31/2023 and conducted by Evaluator Ryan Gardner
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20230131104043
FACILITY NAME:SARAH'S GREAT LIFEFACILITY NUMBER:
331880756
ADMINISTRATOR:UATA, THOMASFACILITY TYPE:
740
ADDRESS:35725 VERDE VISTA WAYTELEPHONE:
(951) 691-8152
CITY:WILDOMARSTATE: CAZIP CODE:
92595
CAPACITY:6CENSUS: 6DATE:
02/06/2023
UNANNOUNCEDTIME BEGAN:
08:56 AM
MET WITH:Brandee Geurkink- Facility ManagerTIME COMPLETED:
10:26 AM
ALLEGATION(S):
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Staff is denying medical records to resident's power of attorney.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Ryan Gardner arrived at the facility unannounced to initiate and deliver findings for the above complaint allegation. LPA met with Facility Manager Brandee Geurkink and explained the reason for the visit.

During today’s visit, LPA toured the facility, conducted interviews with staff, and reviewed, and was provided facility documents.

For allegation, Staff is denying medical records to resident's power of attorney:

During document review, LPA discovered that the party requesting medical documents has legal rights to obtain resident documents. During interviews conducted, LPA discovered that the legal party did not take the correct steps to obtain resident medical documents. The legal party did not provide a written request to the facility to obtain resident records.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Ryan Gardner
LICENSING EVALUATOR SIGNATURE:

DATE: 02/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/06/2023
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-20230131104043
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: SARAH'S GREAT LIFE
FACILITY NUMBER: 331880756
VISIT DATE: 02/06/2023
NARRATIVE
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The licensee and all employees shall reveal or make available confidential information only upon the resident's written consent or that of his designated representative.

Based on the evidence gathered during today’s investigation, the allegation listed above is deemed UNSUBSTANTIATED. A finding that the complaint is UNSUBSTANTIATED means although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur.

During today’s visit, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations.

An exit interview was conducted, and this report (LIC9099) was discussed and provided to Facility Manager Brandee Geurkink, along with a copy of the appeal rights.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Ryan Gardner
LICENSING EVALUATOR SIGNATURE:

DATE: 02/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/06/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2