336413059-9-15-2021-18-AS-JESL-C7BTV6-20210929150326

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 336413059
Report Date: 09/15/2021
Date Signed: 09/15/2021 02:10:16 PM

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 MS29-27
RIVERSIDE, CA 92507

This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/31/2020 and conducted by Evaluator Javina George

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20200831091550

FACILITY NAME:	PEACE AND JOY RCFE		FACILITY NUMBER:	336413059
ADMINISTRATOR:	CECILE JIMENO		FACILITY TYPE:	740
ADDRESS:	26560 HEMPSTEAD COURT		TELEPHONE:	(951) 672-1301
CITY:	SUN CITY	STATE: CA	ZIP CODE:	92586
CAPACITY:	6	CENSUS: 5	DATE:	09/15/2021
		UNANNOUNCED	TIME BEGAN:	01:25 PM
MET WITH:	Administrator Favieruth Jimeno		TIME COMPLETED:	02:20 PM

ALLEGATION(S):

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Facility staff are not following resident's medical orders.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Javina George made an unannounced visit to the facility to deliver findings for the above allegation. LPA George met with Administrator Favieruth Jimeno and explained the purpose for the visit and elements of the allegation. Below is a summary of the investigation.

LPA reviewed documentation such as Resident #1 (R1) physician's report, care plan, nurse reports, individual resident logs, and resident appraisal. Based on the nurses’ notes reviewed, which revealed that R1 was actively going outside to speak with the neighbor, went to get food from a fast food restaurant, watching TV in the living room , going to pick up their medication from the pharmacy, as well as going to the store to buy snacks. Per R1's care plan, R1 was to get out of bed at least every other day. There were days where R1 was noted to be sick and not feeling well. There were no reports to support that on those days R1 gotten up out of the bed. Per the physician’s report dated 10/5/17, R1 is diagnosed with major depressive disorder, and Guillian Barre Syndrome.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Javina George
LICENSING EVALUATOR SIGNATURE:	DATE: 09/15/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 18-AS-20200831091550

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: PEACE AND JOY RCFE	FACILITY NUMBER: 336413059
	VISIT DATE: 09/15/2021

NARRATIVE

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Per Administrator Cecile Jimeno, R1 would have times when they would become depressed and express feelings of hopelessness due to their physical limitations. LPA was unable to successfully interview R1 due to not getting a response or being at the facility when attempts were made. LPA made one final attempt and was informed that R1 was discharged from the facility on 12/29/20 and passed away in January 2021.

Based on interview, and record review LPA was unable to corroborate the allegation of facility staff are not following resident medical orders. The allegation is UNSUBSTANTIATED. A finding that the complaint is UNSUBSTANTIATED means 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 allegation is unsubstantiated at this time.

An exit interview was conducted, and a copy of this report was provided to Administrator Favieruth Jimeno.

SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Javina George
LICENSING EVALUATOR SIGNATURE:	DATE: 09/15/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2021

LIC9099 (FAS) - (06/04)

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