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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331880895
Report Date: 09/02/2021
Date Signed: 09/02/2021 04:39:39 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
08/24/2021 and conducted by Evaluator Crystal Colvin
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20210824111213
FACILITY NAME:ATTENTIVE MANOR IIFACILITY NUMBER:
331880895
ADMINISTRATOR:PECK, CHRISTOPHERFACILITY TYPE:
740
ADDRESS:31221 EL TORO RDTELEPHONE:
(760) 620-5915
CITY:CATHEDRAL CITYSTATE: CAZIP CODE:
92234
CAPACITY:6CENSUS: 4DATE:
09/02/2021
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Chris Peck - AdministratorTIME COMPLETED:
02:45 PM
ALLEGATION(S):
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9
Staff is verbally abusive towards residents

Authorized representative was not provided a refund

Staff did not follow physicians orders for medication
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Crystal Colvin arrived at the facility unannounced for the purpose of initiating an investigation for a complaint with the above allegation(s). LPA Colvin was granted entrance and met with Administrator Chris Peck, who assisted LPA Colvin during today's inspection. Licensee Matt Seigel additionally arrived for part of the investigation and assisted. Below is a summary of today's findings:

Regarding allegation "Staff is verbally abusive towards residents": LPA Colvin interviewed residents, staff, and outside parties regarding the allegation of the complaint. Multiple people interviewed stated that the Licensee, Matt, had on several occasions been verbally abusive to R1. LPA Colvin was also learned that Licensee Matt has been verbally abusive to other resident(s) in the facility. Such reported abuse includes inappropriate statements regarding residents' finances, health, or functional capabilities. Licensee Matt denied allegations. Therefore, based on interviews conducted, the allegation "Staff is verbally abusive towards residents" is SUBSTANTIATED.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Crystal Colvin
LICENSING EVALUATOR SIGNATURE:

DATE: 09/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/02/2021
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 7
Control Number 18-AS-20210824111213
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: ATTENTIVE MANOR II
FACILITY NUMBER: 331880895
VISIT DATE: 09/02/2021
NARRATIVE
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Regarding allegation "Authorized representative was not provided a refund": LPA Colvin reviewed R1's file at the facility as well as interviewed the Licensee and R1's POA. LPA Colvin learned that after R1 left the facility after being there only two months, the Licensee did not provide a refund of the Pre-Admission Fee, which contradicts both Title 22 Regulations and the facility's signed Admissions Agreement. Licensee Matt admitted to not providing R1's POA with any refund except for $100 of "petty cash" left of the $200 given to the facility at the beginning of R1's stay. Therefore, based on record review and interviews, the allegation "Authorized representative was not provided a refund" is SUBSTANTIATED.

Regarding allegation "Staff did not follow physicians orders for medication": LPA Colvin conducted interviews with staff and reviewed R1's file at the facility. LPA Colvin was unable to review the Medication Administration Log (MAR) that the facility utilizes, as the facility had not maintained a copy in R1's archived file, and the copy maintained by the pharmacy was not available for LPA Colvin during today's inspection. It is worth noting that the facility does keep a physical MARs log for residents, but afterwards scans the log to the pharmacy. LPA Colvin observed that while a file for R1 was archived at the facility, this record for R1 was not. LPA Colvin was provided with a blank print out with no signatures or notes for administration of R1's medication. LPA Colvin asked Administrator Chris Peck if the facility does any other notation for "as needed" (PRN) medications on the MARs log, and Chris confirmed that it would be written on the back the time of the administration and the effect it had on the resident. These notes were not available to LPA Colvin during today's inspection, so LPA Colvin cannot verify that staff administered the medications correctly. Therefore, based on interviews and lack of records, the allegation "Staff did not follow physicians orders for medication" is SUBSTANTIATED.

A finding that the complaint is SUBSTANTIATED means that the allegation(s) is valid because the preponderance of the evidence standard has been met.

An exit interview was conducted where this report and appeal rights were discussed. A copy of this report, LIC9099Ds, and appeal rights was provided to Administrator Chris Peck during the exit interview.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Crystal Colvin
LICENSING EVALUATOR SIGNATURE:

DATE: 09/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/02/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 18-AS-20210824111213
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: ATTENTIVE MANOR II
FACILITY NUMBER: 331880895
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/02/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/06/2021
Section Cited
CCR
87507(g)(5)(E)(2)(b)
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Admission Agreements: (g) Admission agreements shall specify...: (5) Refund conditions. (E) Preadmission fees shall be refunded...: 2....shall be refunded...: b. A refund of at least 60 percent...shall be provided if the resident leaves the facility...during the second month of residency. This was not met by:
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Licensee agrees to provide R1's POA of the applicable refund amount of the preadmission fee. Licensee to provide LPA Colvin with proof of refund and proof refund was submitted to R1's POA. Proof requested is due by Plan of Correction date of 9/6/21.
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Based on interviews and record review, the Licensee did not comply with the above regulation with one resident (R1). R1's POA was not provided with a refund of the amount of the preadmission fee as laid out in this regulation and the Admissions Agreement. This was an immediate personal rights violation.
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Type B
09/16/2021
Section Cited
CCR
87465(c)(2)
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Incidental Medical and Dental Care: (c).... facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met:(3) A record of each dose is maintained in the resident's record... This requirement was not met by:
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Licensee agrees to have applicable staff re-trained on record keeping. Licensee to provide LPA Colvin with proof of training by Plan of Correction date of 9/16/21.
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Based on interviews and lack of records, the Licensee did not comply with the above regulation with one resident (R1). LPA Colvin observed there was no record of PRN medication doses administered in R1's file. This was a potential health and safety risk of R1.
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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: Crystal Colvin
LICENSING EVALUATOR SIGNATURE:

DATE: 09/02/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/02/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 7
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
08/24/2021 and conducted by Evaluator Crystal Colvin
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20210824111213

FACILITY NAME:ATTENTIVE MANOR IIFACILITY NUMBER:
331880895
ADMINISTRATOR:PECK, CHRISTOPHERFACILITY TYPE:
740
ADDRESS:31221 EL TORO RDTELEPHONE:
(760) 620-5915
CITY:CATHEDRAL CITYSTATE: CAZIP CODE:
92234
CAPACITY:6CENSUS: 4DATE:
09/02/2021
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Chris Peck - AdministratorTIME COMPLETED:
02:45 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not inform authorized representative of injury

Medications were accessible to resident in care

Staff took resident's personal belongings off the wall of bedroom
INVESTIGATION FINDINGS:
1
2
3
4
5
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7
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9
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12
13
Licensing Program Analyst (LPA) Crystal Colvin arrived at the facility unannounced for the purpose of initiating an investigation for a complaint with the above allegation(s). LPA Colvin was granted entrance and met with Administrator Chris Peck, who assisted LPA Colvin during today's inspection. Licensee Matt Seigel additionally arrived for part of the investigation and assisted. Below is a summary of today's findings:

Regarding allegation "Staff did not inform authorized representative of injury": LPA Colvin conducted interviews with staff, Licensee and outside parties regarding the allegation. LPA Colvin additionally received a photograph of the resident's (R1) injury, which consisted of an abrasion to the head. LPA Colvin was unable to verify the date the photo was taken or confirm that the injury took place at the facility. Additionally, persons other than staff that were interviewed denied ever seeing the injury on R1 while R1 was at the facility. Therefore, due to lack of evidence and supporting information, the allegation of "Staff did not inform authorized representative of injury" is UNSUBSTANTIATED.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Crystal Colvin
LICENSING EVALUATOR SIGNATURE:

DATE: 09/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/02/2021
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 7
Control Number 18-AS-20210824111213
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: ATTENTIVE MANOR II
FACILITY NUMBER: 331880895
VISIT DATE: 09/02/2021
NARRATIVE
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Regarding allegation "Medications were accessible to resident in care": LPA Colvin conducted a tour of the facility and inspected a couple of resident bedrooms and did not observe any medications. LPA Colvin additionally observed the medication closet in the kitchen area to be locked when LPA Colvin arrived. LPA Colvin was not provided with any additional evidence of prior instances of medications being accessible to resident(s). Therefore, based on observations and lack of evidence, the allegation "Medications were accessible to resident in care" is UNSUBSTANTIATED.

Regarding allegation "Staff took resident's personal belongings off the wall of bedroom": LPA Colvin conducted interviews with staff and outside parties regarding the allegation. Interviews conducted conflict on what transpired, and no evidence was provided (or available) for LPA Colvin to review in regards to this allegation. Therefore, based on lack of evidence, the allegation "Staff took resident's personal belongings off the wall of bedroom" is UNSUBSTANTIATED.

A finding of UNSUBSTANTIATED means although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur.

An exit interview was conducted with Administrator Chris Peck and a copy of this report was provided.

SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Crystal Colvin
LICENSING EVALUATOR SIGNATURE:

DATE: 09/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/02/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 7
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
08/24/2021 and conducted by Evaluator Crystal Colvin
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20210824111213

FACILITY NAME:ATTENTIVE MANOR IIFACILITY NUMBER:
331880895
ADMINISTRATOR:PECK, CHRISTOPHERFACILITY TYPE:
740
ADDRESS:31221 EL TORO RDTELEPHONE:
(760) 620-5915
CITY:CATHEDRAL CITYSTATE: CAZIP CODE:
92234
CAPACITY:6CENSUS: 4DATE:
09/02/2021
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Chris Peck - AdministratorTIME COMPLETED:
02:45 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff not allowing family visits
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Crystal Colvin arrived at the facility unannounced for the purpose of initiating an investigation for a complaint with the above allegation(s). LPA Colvin was granted entrance and met with Administrator Chris Peck, who assisted LPA Colvin during today's inspection. Licensee Matt Seigel additionally arrived for part of the investigation and assisted. Below is a summary of today's findings:

Regarding allegation "Staff not allowing family visits": LPA Colvin conducted interviews of staff and outside parties regarding the allegation. Both staff and outside parties conceeded that while the facility does have strict visiting policies due to COVID-19 (appointments requested to be made 24 hours in advance), no individual was ever denied to enter the facility to visit a resident. This agency has investigated the complaint alleging staff not allowing family visits. We have found that the complaint was UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. We have therefore dismissed the complaint.
An exit interview was conducted with Administrator Chris Peck and a copy of this report was provided.
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Crystal Colvin
LICENSING EVALUATOR SIGNATURE:

DATE: 09/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/02/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 18-AS-20210824111213
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: ATTENTIVE MANOR II
FACILITY NUMBER: 331880895
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/02/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/06/2021
Section Cited
CCR
87468.1(a)(1)
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7
Personal Rights of Residents in All Facilities: (a) Residents...shall have all of the following...:
(1) To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement was not met as evidenced by:
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Licensee agrees to have staff retrained on Reporting Requirements. Licensee to provide LPA Colvin with a date for staff training by the Plan of Correction date of 9/3/21, and a proof of staff training once completed.
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Based on interviews conducted, the Licensee did not comply with the above regulation with one staff member (Licensee). Interviews revealed that Licensee has been verablly abusive to more than one resident in care. This was an immediate personal right violation to multiple residents, including R1.
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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: Crystal Colvin
LICENSING EVALUATOR SIGNATURE:

DATE: 09/02/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/02/2021
LIC9099 (FAS) - (06/04)
Page: 7 of 7