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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331881233
Report Date: 08/25/2025
Date Signed: 08/25/2025 10:06:19 AM

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
08/21/2025 and conducted by Evaluator Javina George
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20250821141624
FACILITY NAME:ANNACARE2 LLCFACILITY NUMBER:
331881233
ADMINISTRATOR:BLANCAFLOR, ANNALISAFACILITY TYPE:
740
ADDRESS:20846 SUNDROPS LANETELEPHONE:
(951) 399-0363
CITY:WILDOMARSTATE: ZIP CODE:
92592
CAPACITY:6CENSUS: 6DATE:
08/25/2025
UNANNOUNCEDTIME BEGAN:
08:42 AM
MET WITH:Annalisa Blancaflor, administrator TIME COMPLETED:
10:25 AM
ALLEGATION(S):
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Facility staff failed to provide resident's records to authorized party.
INVESTIGATION FINDINGS:
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On 08/25/25 Licensing Program Analyst (LPA) Javina George made an unannounced visit to the facility to commence a complaint investigation for the allegation noted above. LPA met with Administrator Annalisa Blancaflor, and explained the elements of the allegation. The allegation was investigated and, the investigation consisted of interviews and records review.

On 08/21/25 Community Care Licensing received a complaint alleging that the facility staff failed to provide Resident's #1 (R1) records to authorized party. Per an interview with administrator Annalisa Blancaflor who confirmed that she was aware of the initial request that was received via written letter and then received a follow up phone call. Blancaflor could not recall the dates. Blancaflor stated that she made a request to be provided with ample time to produce the records, but there was no date agreed upon. During today's visit Blancaflor provided LPA with a copy of the written request that was dated 08/13/25, but was sent via FedEx and received on 08/15/25. Per a records review of the written request it states "not to exceed two business days, at a cost not to exceed the community standards for photocopies". The letter provides further
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Carolyn Tuba
LICENSING EVALUATOR NAME: Javina George
LICENSING EVALUATOR SIGNATURE:

DATE: 08/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2025
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-20250821141624
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: 08/25/2025
NARRATIVE
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instructions for facility staff to contact the office to make arrangements to arrange the photocopying of R1s file, within two working days. Based on interviews and and records review the allegation of facility staff failed to provide resident's records to authorized representative is substantiated. A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

Due to this being the second time that the facility is being cited for the same deficiency, within a 12 month period, an immediate civil penalty of $1000 is being assessed.

An exit interview was conducted and a copy of this report, 9099C, 9099D, LIC421IM, and appeal rights were reviewed and provided to Annalisa Blancaflor, Administrator.

SUPERVISORS NAME: Carolyn Tuba
LICENSING EVALUATOR NAME: Javina George
LICENSING EVALUATOR SIGNATURE:

DATE: 08/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 18-AS-20250821141624
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: 08/25/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/25/2025
Section Cited
CCR
87506(c)(1)
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Resident Records (c) All information and records obtained from or regarding residents shall be confidential. (1) The licensee shall be responsible for storing active and inactive records and for safeguarding the confidentiality of their contents. The licensee and all employees shall reveal or make
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There is no POC due at this time. R1s file was provided to LPA during today's visit (8/25/25) by adminstrator Blancaflor.
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available confidential information only upon the resident's written consent or that of his designated representative. This requirement is not met as evidenced by: the licensee did not provide R1s records, which posed a potential health, safety and personal rights risk to persons 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: Carolyn Tuba
LICENSING EVALUATOR NAME: Javina George
LICENSING EVALUATOR SIGNATURE:

DATE: 08/25/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3