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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336412255
Report Date: 10/12/2021
Date Signed: 10/12/2021 03:19:16 PM

Document Has Been Signed on 10/12/2021 03:19 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:LIFESTYLE HOME CARE IIFACILITY NUMBER:
336412255
ADMINISTRATOR:MARY MATEASFACILITY TYPE:
740
ADDRESS:5417 SKYLOFT DRIVETELEPHONE:
(951) 360-1622
CITY:RIVERSIDESTATE: CAZIP CODE:
92509
CAPACITY: 6CENSUS: 5DATE:
10/12/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:15 PM
MET WITH:Mary Mateas - Licensee/AdministratorTIME COMPLETED:
03:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Crystal Colvin arrived at the facility unannounced for the purpose of delivering findings on a complaint 18-AS-20210720165959). LPA Colvin met with Licensee/Administrator Mary Mateas and advised them of the purpose of the visit. During LPA Colvin's visit, LPA Colvin addressed the following issue which was discovered during the investigation:

When LPA Colvin interviewed Licensee/Administrator Mary Mateas regarding the complaint listed above, Mary told LPA Colvin that she had told the resident (R1) "you better not call Licensing or I'll be very upset". Mary restated this fact to LPA Colvin multiple times in the single interview. Facility staff, especially Licensees and Administrators, are not to discourage residents from contacting Community Care Licensing, especially when the resident has a complaint or concern regarding the facility, staff, or care being provided. Deficiency cited.

LPA Colvin conducted an exit interview with Licensee/Administrator Mary Mateas, who refused to sign the report, and a copy of this report, LIC809D and appeal rights were provided.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Crystal Colvin
LICENSING EVALUATOR SIGNATURE: DATE: 10/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/12/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 10/12/2021 03:19 PM - It Cannot Be Edited

Citations on this Visit Report are Under Appeal!


Created By: Crystal Colvin On 10/08/2021 at 04:34 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: LIFESTYLE HOME CARE II
FACILITY NUMBER: 336412255

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/12/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Under Appeal
Type A
10/13/2021
Section Cited
CCR
87468.1(a)(3)

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Personal Rights of Residents in All Facilities: (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (3) To be free from...intimidation, abuse, or other actions of a punitive nature... This was not met by:
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Licensee agrees to not discourage residents in the future from contacting Licensing. Licensee to provide LPA Colvin with a Statement of Understanding. Licensee additionally agrees to post additional posters for the Community Care Licensing Complaint Line (1-844-LET-US-NO) in near all resident bedrooms, to ensure they
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Based on statements made by Licensee, the Licensee did not comply with the above regulation with at least one resident (R1). Licensee Mary freely told LPA Colvin that they told R1 not to contact Licensing. This was an immediate personal rights violation.
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are aware of who they can contact if they have a concern. Photographic proof of postings and Statement of Understanding due 10/13/21.

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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.
SUPERVISOR'S NAME:Joel Esquivel
LICENSING EVALUATOR NAME:Crystal Colvin
LICENSING EVALUATOR SIGNATURE:
DATE: 10/12/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/12/2021


LIC809 (FAS) - (06/04)
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