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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 336411237
Report Date: 07/29/2021
Date Signed: 07/29/2021 09:32:30 AM

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 MS29-26
RIVERSIDE, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/29/2020 and conducted by Evaluator Shaunte Henry
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20200129112320
FACILITY NAME:HAPPY NESTFACILITY NUMBER:
336411237
ADMINISTRATOR:CLAIRE ITCHONFACILITY TYPE:
740
ADDRESS:3140 E. VISTA CHINOTELEPHONE:
(760) 318-9973
CITY:PALM SPRINGSSTATE: CAZIP CODE:
92262
CAPACITY:6CENSUS: 6DATE:
07/29/2021
UNANNOUNCEDTIME BEGAN:
09:25 AM
MET WITH:Myrna Lomboy, caregiverTIME COMPLETED:
09:45 AM
ALLEGATION(S):
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Resident has multiple unstageable pressure injuries.
Illegal eviction.
INVESTIGATION FINDINGS:
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On 7/29/21 Licensing Program Analyst (LPA) conducted an unannounced visit for the purpose of delivering the findings to the above allegations. LPA met with Myrna Lomboy, explained the nature of the visit and was granted entry.

The investigation, which consisted of interviews and file reviews reveled that the Resident 1 (R1) did not have multiple unstageable pressure injuries and was not illegally evicted. On 1/26/20, staff took a picture of a red spots on Resident 1 (R1)'s buttocks and notified Claire and George Camua. R1 sustained redness more consistent with a stage 1 wound. On 1/27/20 R1 was taken to the hospital for a decline in health and would be discharged back to the facility onto hospice. R1 was placed on life support and was removed by their Power of Attorney (POA). R1 expired on 2/1/20, which is the reason he did not return to the facility. In regard to the illegal eviction, R1's POA called the facility from the hospital and told the facility that R1 would not be returning to the hospital because R1's health was declining and R1 would be passing soon. There was never any conversation about an eviction. ***continued on 9099C***

Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Edna Musoke
LICENSING EVALUATOR NAME: Shaunte Henry
LICENSING EVALUATOR SIGNATURE:

DATE: 07/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2021
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-20200129112320
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: HAPPY NEST
FACILITY NUMBER: 336411237
VISIT DATE: 07/29/2021
NARRATIVE
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*** continued from 9099***

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, therefore the allegations are UNSUBSTANTIATED at this time.

An exit interview was conducted where this report was discussed with and provided to Myrna Lomboy
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Shaunte Henry
LICENSING EVALUATOR SIGNATURE:

DATE: 07/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 2