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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331881233
Report Date: 02/09/2024
Date Signed: 02/09/2024 12:46:58 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 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
02/02/2024 and conducted by Evaluator Sara Martinez
COMPLAINT CONTROL NUMBER: 18-AS-20240202081314
FACILITY NAME:ANNACARE2 LLCFACILITY NUMBER:
331881233
ADMINISTRATOR:BLANCAFLOR, ANNALISAFACILITY TYPE:
740
ADDRESS:20846 SUNDROPS LANETELEPHONE:
(951) 399-0363
CITY:WILDOMARSTATE: CAZIP CODE:
92592
CAPACITY:6CENSUS: 7DATE:
02/09/2024
UNANNOUNCEDTIME BEGAN:
09:24 AM
MET WITH:Caregiver - Milanie EncinasTIME COMPLETED:
12:58 PM
ALLEGATION(S):
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Facility is operating over the capacity.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Sara Martinez conducted an unannounced visit to initiate and deliver findings regarding the allegation listed above. LPA was granted entry and met with caregiver Milanie Encinas, who was Informed of the purpose of the visit. LPA toured the facility, conducted interviews, and collected pertinent documents regarding the allegation listed above.

Regarding the allegation “Facility is operating over the capacity”, upon arrival LPA asked staff the number of residents currently residing in the facility. Staff One (S1) stated there were currently seven (7) residents. Record Review reveals the facility is licensed for a capacity of 6 and during LPA’s tour of the facility LPA observed a total of 7 residents. It was reported Resident One (R1) is the owner of the home and is treated like a resident but R1 is a non-paying resident. Record Review revealed R1 has a resident file with a signed admissions agreement that states R1 is “non-payment”.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Sara Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 02/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2024
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 3
Control Number 18-AS-20240202081314
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: ANNACARE2 LLC
FACILITY NUMBER: 331881233
VISIT DATE: 02/09/2024
NARRATIVE
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During the visit, LPA observed staff providing care and supervision to R1 and the six (6) residents residing at the facility. Therefore based on LPA’s observations, record review, and interviews, the allegation “Facility is operating over the capacity” has been deemed SUBSTANTIATED at this time.

A finding that the complaint is SUBSTANTIATED means that the allegation is valid. The facility was cited civil penalties per Title 22 division 6 chapter 8 section 87204(a) Limitations - Capacity and Ambulatory Status.

An exit interview was conducted, and a copy of this report was given to Encinas along with the LIC 9099-D, LIC 421IM, LIC 811, and appeal rights.
SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Sara Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 02/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 18-AS-20240202081314
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: ANNACARE2 LLC
FACILITY NUMBER: 331881233
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/09/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/16/2024
Section Cited
CCR
87204(a)
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Limitations - Capacity and Ambulatory Status: (a) A licensee shall not operate a facility beyond the conditions and limitations ...including specification of the maximum number of persons who may receive services at any one time...This requirement was not being met as evidenced by:
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Licensee shall relocate the resident the facility is not licensed to provide care and supervision due to over capacity.Proof of resident relocation shall be submitted to the Department no later than and of POC date 02/16/2024
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The facility is licensed for a capacity of 6 residents, however during the visit on 02/09/2024, 7 residents were observed to be residing at the home. This poses an immediate health and safety risk to residents in care.
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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: Rikesha Stamps
LICENSING EVALUATOR NAME: Sara Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 02/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3