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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 336427427
Report Date: 07/29/2024
Date Signed: 07/29/2024 12:17:23 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 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
08/11/2021 and conducted by Evaluator Kathleen Banrasavong
COMPLAINT CONTROL NUMBER: 18-AS-20210811145213
FACILITY NAME:NEW HOPE RESIDENTIAL ELDER CARE II LLCFACILITY NUMBER:
336427427
ADMINISTRATOR:MIKENAS, ANNIE JANEFACILITY TYPE:
740
ADDRESS:30221 POWDERHORN LANETELEPHONE:
(951) 467-0330
CITY:MURRIETASTATE: CAZIP CODE:
92563
CAPACITY:6CENSUS: 6DATE:
07/29/2024
UNANNOUNCEDTIME BEGAN:
11:40 AM
MET WITH:Administrator, Jane MikenasTIME COMPLETED:
12:35 PM
ALLEGATION(S):
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Resident sustained multiple scratches while in care.
Resident not administered medication as prescribed.
Medication not locked in a cabinet.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kathleen Banrasavong conducted an unannounced visit to deliver findings for a complaint investigation regarding the above allegations. LPA met with Administrator, Jane Mikenas where LPA explained the purpose of the visit and the elements of the allegations. The investigation consisted of observation, interviews with staff members and residents, and records review.

On 08/11/2021, Community Care Licensing received a complaint alleging Resident sustained multiple scratches while in care, Resident not administered medication as prescribed, and medication not locked in a cabinet. In regards to the allegation of the medication not locked, LPA interviewed Administrator, Jane Mikenas and she denied the allegation. Administrator stated that facility always locks the medications in the hallway door. LPA interviewed the staff members, who stated that the medications are always locked in the hallway closet. LPA made observation during her subsequent visit that confirmed medications are stored and locked in a centrally stored location in the hallway. The initial visit made by a previous LPA was not able to confirm or deny this allegation during the initiation of the complaint in 2021.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Kathleen Banrasavong
LICENSING EVALUATOR SIGNATURE:

DATE: 07/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2024
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 3
Control Number 18-AS-20210811145213
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: NEW HOPE RESIDENTIAL ELDER CARE II LLC
FACILITY NUMBER: 336427427
VISIT DATE: 07/29/2024
NARRATIVE
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In regards to the allegation that Resident sustained multiple scratches while in care. LPA was not able to interview Resident 1 (R1). R1 passed away on 08/15/2021. LPA interviewed Administrator who stated that there were no incidents that occurred where any facility staff member scratched the resident. LPA interviewed staff members who worked at the facility in 2021, who stated that they handled R1 with care and denied scratching R1. LPA interviewed residents who have been at the facility since 2021. Information obtained from residents indicated there was no issues with staff or care and supervision during the entirety of their residency at the facilities. LPA was unable to contact a representative from Arbor Hospice to obtain additional information. LPA reviewed the notes from hospice agency, which did not indicate any abnormal scratches.

In regards to the allegation that residents are not administering medication as prescribed, LPA interviewed Administrator stated that staff review doctor’s orders and the medication is given to the residents on time, every day. Information obtained from interviews with staff members who worked at the facility in 2021 indicated that staff administer resident’s medications following doctor’s orders. Residents currently placed at the facility indicated no issues with receiving their medications as prescribed. LPA was unable to contact a representative from Arbor Hospice to obtain additional information. During the LPA’s record review, Medications Administrator Records (MARS) appeared to have been provided and filled out correctly. LPA also reviewed R1’s Centrally Stored Medication log. No additional documents were able to be reviewed due to the time frame since R1’s passing.
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Kathleen Banrasavong
LICENSING EVALUATOR SIGNATURE:

DATE: 07/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 18-AS-20210811145213
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: NEW HOPE RESIDENTIAL ELDER CARE II LLC
FACILITY NUMBER: 336427427
VISIT DATE: 07/29/2024
NARRATIVE
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Based on LPA’s observation, interviews conducted, and record review, the allegations that R1 sustained multiple scratches while in care, R1 not administered medication as prescribed, and medication not locked in a cabinet is unsubstantiated due to the inability to interview pertinent parties and review pertinent documentation. A finding of unsubstantiated means the allegations may have happened or is valid, but there is not a preponderance of evidence to prove the alleged violations did or did not occur. Therefore, the allegations are unsubstantiated.

An exit interview was conducted, and a copy of this report was discussed with and provided to the Administrator, Jane Mikenas.
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Kathleen Banrasavong
LICENSING EVALUATOR SIGNATURE:

DATE: 07/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3