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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331880980
Report Date: 07/22/2022
Date Signed: 07/22/2022 12:26:10 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
RIVERSIDE, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/15/2022 and conducted by Evaluator Crystal Colvin
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20220715115207
FACILITY NAME:MAMA ANGELINA COCONOCHOFACILITY NUMBER:
331880980
ADMINISTRATOR:GONZALEZ, MARIA ROSARIOFACILITY TYPE:
740
ADDRESS:862 PIKE DRIVETELEPHONE:
(951) 335-1239
CITY:HEMETSTATE: CAZIP CODE:
92544
CAPACITY:6CENSUS: 5DATE:
07/22/2022
UNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Maria Gonzalez - AdministratorTIME COMPLETED:
11:00 AM
ALLEGATION(S):
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Lack of supervision resulting in resident leaving the facility
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Crystal Colvin arrived at the facility unannounced in order to initiate an investigation of a complaint with the above allegation(s). LPA identified herself and discussed the purpose of the visit and the elements of the allegation(s) with Administrator Maria Gonzalez. Below is a summary of the complaint investigation findings:

Regarding allegation "Lack of supervision resulting in resident leaving the facility": LPA Colvin confirmed through interviews that on 7/4/22, resident (R1) eloped from the facility without the knowledge of facility staff. LPA Colvin confirmed through record review that R1 is diagnosed with Dementia and has a history of wandering behavior. Despite these facts, LPA Colvin was informed by the Administrator that R1 eloped through the facility during a brief period of time after dinner, in which R1 usually retreats to their room. During this time, R1 left the facility via their bedroom window. LPA Colvin was additionally informed that R1 has lived at the facility for over two years and has never eloped from the facility. Additional interviews/hospital records confirm the time that R1 was picked up by local law enforecement and brought to the hospital (around 6pm).
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Crystal Colvin
LICENSING EVALUATOR SIGNATURE:

DATE: 07/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2022
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 18-AS-20220715115207
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: MAMA ANGELINA COCONOCHO
FACILITY NUMBER: 331880980
VISIT DATE: 07/22/2022
NARRATIVE
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These additional interviews/hospital records additionally confirm that R1 had left the facility through their bedroom window. Since evidence supports the Administrator's recollection of the event, the circumstances surrounding the elopement do not suggest a lack of supervision by staff, as R1 exited through a window (which is low in the wall and is feasible for R1 to have exited from) in their bedroom during a brief period of time where staff did not have line of sight on R1, and it was normal for R1 to be in their private bedroom at this time. Additionally, R1 had no prior elopements from the facility in the last two years since admission. R1's elopement from the facility was unusual in R1's established behavior at the facility as well as the method used to exit the premises. Therefore, based on interviews, observations, and hospital records, the allegation "Lack of supervision resulting in resident leaving the facility" 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 Maria Gonzalez and a copy of this report was provided.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Crystal Colvin
LICENSING EVALUATOR SIGNATURE:

DATE: 07/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2