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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 336402301
Report Date: 07/25/2024
Date Signed: 07/25/2024 04:10:27 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
07/20/2024 and conducted by Evaluator Janette Romero
COMPLAINT CONTROL NUMBER: 18-AS-20240720174927
FACILITY NAME:HAZEL GUEST HOMEFACILITY NUMBER:
336402301
ADMINISTRATOR:HAZEL ABELLAFACILITY TYPE:
740
ADDRESS:24641 SUPERIOR AVENUETELEPHONE:
(951) 601-0689
CITY:MORENO VALLEYSTATE: CAZIP CODE:
92551
CAPACITY:6CENSUS: 4DATE:
07/25/2024
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Administrator, Hazel AbellaTIME COMPLETED:
04:15 PM
ALLEGATION(S):
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Licensee did not seek appropriate medical attention for resident in care
INVESTIGATION FINDINGS:
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On 7/25/2024, Licensing Program Analyst (LPA), Janette Romero arrived unannounced to initiate the investigation into the allegation listed above. LPA met with Administrator, Hazel Abella who was informed of the purpose of the visit.

It was alleged on 7/9/2024 Administrator, Hazel Abella reported they would schedule a dentist appointment for Client 1 (C1) due to observations of bleeding gums and tooth pain while in day program. It was further alleged Administrator Abella did not seek appropriate medical attention for C1. LPA toured the facility, conducted interviews, and obtained copies of pertinent records. Administrator Abella was interviewed and reported on 7/9/2024, C1’s day program called her and informed her they observed blood coming from C1’s mouth and when asked, C1 reported they had a toothache.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Janette Romero
LICENSING EVALUATOR SIGNATURE:

DATE: 07/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/25/2024
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-20240720174927
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: HAZEL GUEST HOME
FACILITY NUMBER: 336402301
VISIT DATE: 07/25/2024
NARRATIVE
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Administrator Abella reported on 7/9/2024, C1 arrived to the facility from day program, and she checked C1’s mouth and did not observe any bleeding, swelling, or indication of pain. Administrator Abella reported on 7/9/2024, she called C1’s dentist office and they reported C1’s dentist was unavailable. Administrator Abella added the dentist’s office also informed her C1’s last dentist visit was on 8/8/2023 and C1’s dental insurance would not cover any dental expenses until after 8/8/2024. Administrator Abella reported prior to this incident, C1 had a dentist appointment for a routine visit scheduled on 8/12/2024. Administrator Abella reported she monitored C1’s mouth from 7/9/2024 to 7/13/2024 and did not observe any blood, so she did not feel C1 required immediate medical attention. Administrator Abella reported C1 did not express any pain or signs of discomfort, so she decided to wait for C1 to visit the dentist on 8/12/2024. Administrator Abella explained that on 7/18/2024, she received a call from Inland Regional Center inquiring about the situation. Administrator Abella reported she scheduled an appointment with a different dentist and C1 received medical attention on 7/19/2024.

LPA reviewed C1’s Dental Appointment Report dated 8/8/2023, which notes C1 had a routine exam and indicated follow up was required for a specific tooth number. Administrator Abella explained the facility forgot to follow up with the dentist's office to pursue treatment for C1. LPA reviewed the visit referral for C1’s 7/19/2024 dental visit, which noted an extraction referral for the same tooth indicated on the 8/8/2023 visit. LPA reviewed C1’s Individual Program Plan (IPP) dated 6/13/2024, which notes C1 performs their own personal care activities including brushing their teeth, when reminded. Administrator Abella reported the facility reminds C1 to brush their teeth every morning and evening. C1’s IPP indicates C1 uses words to communicate, but their speech is not easily understood. LPA attempted to conduct an interview with C1 but was unable to establish effective communication. LPA reviewed C1’s admission agreement dated 2/6/2018 and subsection a(9) lists assistance with bathing and personal care as need as a basic service provided by the facility. Based on LPA’s interviews conducted, and records reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California Code of Regulations (Title 22, Division 6, Chapter 1), is being cited on the attached LIC 9099 D. An exit interview was conducted, and a copy of this report was provided to Administrator Abella along with a Confidential Names List (LIC 811) and Appeal Rights.

SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Janette Romero
LICENSING EVALUATOR SIGNATURE:

DATE: 07/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/25/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3
Control Number 18-AS-20240720174927
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: HAZEL GUEST HOME
FACILITY NUMBER: 336402301
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/25/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/02/2024
Section Cited
CCR
80075(a)
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(a) The licensee shall ensure that each client receives necessary first aid and other needed medical or dental services...
This requirement was not met as evidenced by:
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Administrator Abella reported they will conduct a staff training regarding seeking timely medical treament for clients in care. Administrator Abella added Proof of Correction (POC) will be submitted to LPA by close of business on POC due date.
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On 7/9/2024, the facility was informed C1 was observed with blood coming from their mouth and tooth pain and did not seek medical treatment until 7/19/2024. This poses a potential health and personal rights risks to clients 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: Tricia Danielson
LICENSING EVALUATOR NAME: Janette Romero
LICENSING EVALUATOR SIGNATURE:

DATE: 07/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/25/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3