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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 336408489
Report Date: 11/04/2022
Date Signed: 11/04/2022 10:02:58 AM

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
01/21/2021 and conducted by Evaluator Venus Mixson
COMPLAINT CONTROL NUMBER: 18-AS-20210121132515
FACILITY NAME:CATHEDRAL MANORFACILITY NUMBER:
336408489
ADMINISTRATOR:JOLI FRIAS VICENCIOFACILITY TYPE:
740
ADDRESS:31222 EL TORO ROADTELEPHONE:
(760) 202-7203
CITY:CATHEDRAL CITYSTATE: CAZIP CODE:
92234
CAPACITY:6CENSUS: DATE:
11/04/2022
UNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:ADMINISTRATOR, JOLI VICENCIOTIME COMPLETED:
10:10 AM
ALLEGATION(S):
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Facility houses a bedridden resident without proper fire clearance.
INVESTIGATION FINDINGS:
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On November 04, 2022, Licensing Program Analyst (LPA), Venus Mixson conducted a visit to the facility and met with Administrator, Verly Frias. The visit was conducted in order to provide the findings for the investigation pertaining to the listed allegation.
On January 21, 2021, Community Care Licensing received information which stated facility houses a bedridden resident without proper fire clearance. The investigation included interviews and review of documents. The information obtained revealed that Resident 1 (R1) was admitted to the facility on January 6, 2020. Based on review of physician’s report and case plans and was deemed bedridden at the time of placement, the facility did not have an approved fire clearance for a bedridden resident. The Administrator reported he thought he could admit bedridden residents as long as hospice care was in place.
The preponderance of evidence standard has been met and the allegation is substantiated. This allegation posed an immediate health and safety risk to R1. The facility was cited on the attached LIC9099D. A copy of this report, along with the LIC 9099D page and appeal rights were provided.

Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Venus Mixson
LICENSING EVALUATOR SIGNATURE:

DATE: 11/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2022
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-20210121132515
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: CATHEDRAL MANOR
FACILITY NUMBER: 336408489
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/04/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/14/2022
Section Cited
CCR
87202(a)(2)
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87202 (a)(2)-Fire Clearance
All facilities shall maintain an approved fire clearance prior to accepting bedridden clients.
This was not met by evidence by:
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Administrator will ensure any client accepted is allowed under the previsions of the license. Administrator will provide written statement indicating that he understands the regulation and provisions of licensure.
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Facility accepted placement of R1 who was deemed bedridden
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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: Jazmond D Harris
LICENSING EVALUATOR NAME: Venus Mixson
LICENSING EVALUATOR SIGNATURE:

DATE: 11/03/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2