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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 336413083
Report Date: 11/04/2021
Date Signed: 11/04/2021 02:39:34 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
11/04/2021 and conducted by Evaluator Javina George
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20211104123029
FACILITY NAME:GEM'S SENIOR LIVING IIFACILITY NUMBER:
336413083
ADMINISTRATOR:GERLITA HIGAFACILITY TYPE:
740
ADDRESS:28291 PORTSMOUTH DRIVETELEPHONE:
(951) 301-4134
CITY:SUN CITYSTATE: CAZIP CODE:
92586
CAPACITY:6CENSUS: 6DATE:
11/04/2021
UNANNOUNCEDTIME BEGAN:
12:44 PM
MET WITH:Caregiver Crispin DizonTIME COMPLETED:
02:55 PM
ALLEGATION(S):
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Staff member physically abused resident while in care.
Staff member verbally abused resident while in care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Javina George made an unannounced visit to the facility to commence a complaint investigation for the allegation(s) listed above. LPA was greeted and granted entry by Caregiver Crispin Dizon. LPA met with Administrator via telephone.

Staff were interviewed and denied resident being physically abused. Staff stated R1 is a new admit whom recently experienced a significant loss, as well as other life changing events such as having a change of condition and being moved. Upon admission R1 also had scabs that they would pick at as well as a rash on their body.

R1 was interviewed and denied allegation of being physically abused, as they said that they could not remember if it happened or not. Additional witness interviews were conducted where it was reported that R1 had admitted to making up the allegations because they no longer wanted to be at the facility, and would like to go back home.

***Continued on 9099C


Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Javina George
LICENSING EVALUATOR SIGNATURE:

DATE: 11/04/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2021
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-20211104123029
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: GEM'S SENIOR LIVING II
FACILITY NUMBER: 336413083
VISIT DATE: 11/04/2021
NARRATIVE
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Based on the information obtained there is not enough evidence to state that Staff member physically abused resident while in care, therefore the allegation is UNSUBSTANTIATED.

Allegation: Staff member verbally abused resident while in care.
Staff were interviewed and denied resident being verbally abused. Staff stated R1 is a new admit whom recently experienced a significant loss, as well as other life changing events such as having a change of condition and being moved.

R1 was interviewed and denied allegation of being verbally abused, as they said that they could not remember if it happened or not. Additional witness interviews were conducted where it was reported that R1 had admitted to making up the allegations because they no longer wanted to be at the facility, and would like to go back home.

Therefore the allegation of Staff member verbally abused resident while in care is UNSUBSTANTIATED. A finding that is UNSUBSTANTIATED means that although the allegation may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated at this time.

An exit interview was conducted, and a copy of this report was reviewed with and provided to Caregiver Crispin Dizon
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Javina George
LICENSING EVALUATOR SIGNATURE:

DATE: 11/04/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 2