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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 336413059
Report Date: 12/23/2021
Date Signed: 12/23/2021 02:50:26 PM

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
06/11/2020 and conducted by Evaluator Venus Mixson
COMPLAINT CONTROL NUMBER: 18-AS-20200611094154
FACILITY NAME:PEACE AND JOY RCFEFACILITY NUMBER:
336413059
ADMINISTRATOR:CECILE JIMENOFACILITY TYPE:
740
ADDRESS:26560 HEMPSTEAD COURTTELEPHONE:
(951) 672-1301
CITY:SUN CITYSTATE: CAZIP CODE:
92586
CAPACITY:6CENSUS: DATE:
12/23/2021
UNANNOUNCEDTIME BEGAN:
11:10 AM
MET WITH:TIME COMPLETED:
11:11 AM
ALLEGATION(S):
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#1. Staff is failing to administer resident's medication as prescribed.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Venus Mixson and Licensing Program Manager (LPM) Joel Esquivel made an unannounced visit to the facility and met with administrator Favie Jimeno, to investigate the above allegation.
Regarding the above allegation LPA did an investigation which consisted of touring the facility, interviewing the staff, reviewed documentation and medications.

Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Venus Mixson
LICENSING EVALUATOR SIGNATURE:

DATE: 12/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/23/2021
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 5
Control Number 18-AS-20200611094154
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: 12/23/2021
NARRATIVE
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Based on the information reviewed LPA found several discrepancies with the dispensing of medications. LPA found several medications that were not being dispensed as per physicians instructions; as such the allegation; Staff is failing to administer resident's medication as prescribed is found to be Substantiated. A substantiated finding means the totality of the evidence supports the allegation. California Code of Regulations, (Title 22, Division 6 & Chapter 1) is being cited on the attached LIC 9099D.

Exit interview conducted and copy of appeal rights and this report was provided to administrator Favie Jimeno.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Venus Mixson
LICENSING EVALUATOR SIGNATURE:

DATE: 12/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/23/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 5
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
06/11/2020 and conducted by Evaluator Venus Mixson
COMPLAINT CONTROL NUMBER: 18-AS-20200611094154

FACILITY NAME:PEACE AND JOY RCFEFACILITY NUMBER:
336413059
ADMINISTRATOR:CECILE JIMENOFACILITY TYPE:
740
ADDRESS:26560 HEMPSTEAD COURTTELEPHONE:
(951) 672-1301
CITY:SUN CITYSTATE: CAZIP CODE:
92586
CAPACITY:6CENSUS: DATE:
12/23/2021
UNANNOUNCEDTIME BEGAN:
11:10 AM
MET WITH:TIME COMPLETED:
11:11 AM
ALLEGATION(S):
1
2
3
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5
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9
#2. Staff are mishandling resident personal funds.

#3. Staff fail to ensure resident is properly fed while in care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Venus Mixson and Licensing Program Manager (LPM) Joel Esquivel made an unannounced visit to the facility and met with administrator Favie Jimeno, to investigate the above allegations.

Regarding allegation #2 Staff are mishandling resident personal funds. LPA investigation consisted of but not limited to; touring the facility, interviewing staff and reviewed facility documentation.
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Venus Mixson
LICENSING EVALUATOR SIGNATURE:

DATE: 12/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/23/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 18-AS-20200611094154
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: 12/23/2021
NARRATIVE
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Based on the information reviewed LPA found evidence that showed that the resident #1 (R1) handled own funds. Facility staff did not handle R1s cash in any way and was self sufficient as per documentation. As such the allegation, Staff are mishandling resident personal funds, was deemed as UNFOUNDED.

Regarding allegation #3. Staff fail to ensure resident is properly fed while in care. LPA found that R1 had no diet restrictions. Facility provides food and snacks to all other resident. However, R1 did not approve of this food and as such would leave the facility to purchase his own food selection via public transportation. Therefore the allegation, Staff fail to ensure resident is properly fed while in care is deemed as Unfounded.

We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis.

An exit interview was conducted with administrator Favie Jimeno and a copy of this report along with LIC 811 was provided.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Venus Mixson
LICENSING EVALUATOR SIGNATURE:

DATE: 12/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/23/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 18-AS-20200611094154
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/23/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/31/2021
Section Cited
CCR
87465(c)(2)
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If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met:
Once ordered by the physician the medication is given according to the physician's directions.
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The licensee will provide training to all staff regarding proper dispensing of medication by 12/31/2021.
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This was not met because the facility could not prove that the medication was dispensed as per physicans instructions.
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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: Joel Esquivel
LICENSING EVALUATOR NAME: Venus Mixson
LICENSING EVALUATOR SIGNATURE:

DATE: 12/23/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/23/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 5