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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374604137
Report Date: 02/16/2023
Date Signed: 02/16/2023 11:25:53 AM

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
01/31/2023 and conducted by Evaluator Tricia Danielson
COMPLAINT CONTROL NUMBER: 18-AS-20230131104737
FACILITY NAME:AFFIRMATIVE'S ELITE HOMEFACILITY NUMBER:
374604137
ADMINISTRATOR:HARAGOS, RONNIFACILITY TYPE:
740
ADDRESS:1729 SUMMIT DRTELEPHONE:
(760) 294-0357
CITY:ESCONDIDOSTATE: CAZIP CODE:
92027
CAPACITY:6CENSUS: 5DATE:
02/16/2023
ANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:Nieves Betancourt, CaregiverTIME COMPLETED:
10:30 AM
ALLEGATION(S):
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Violation of a resident's personal rights
INVESTIGATION FINDINGS:
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Licensing Program Analyst(LPA) Tricia Danielson arrived unannounced to the facility to conclude an investigation into the allegation above. LPA met with Caregiver Nieves Betancourt and explained the purpose of the visit. LPA also spoke with Administrator Ronni Haragos via telephone.
Regarding the allegation "Violation of a resident's personal rights", it was alleged that the personal rights of Resident #1(R1) were violated when they were prohibited from attending their day center due to the fear that they would bring germs back to the facility and cause the other residents to become ill with either the flu or COVID. It was further alleged that LIC Haragos would not permit R1 to board the bus to the day center. It was also alleged that when R1 recently moved from the facility LIC Haragos moved all the other residents into a back room and would not permit R1 to say goodbye to them.
The investigation revealed LIC Haragos had inquired with LPA on November 30, 2022 regarding the legality of preventing a resident from leaving the facility to attend a day program throughout the flu season, specifically through the end of March. On December 1, 2022, LPA informed LIC Haragos that it was unlawful to restrict any resident’s movement to and from the facility. Interview conducted with LIC Haragos revealed she asked R1 if it "would be OK" if they did not attend their day program and if they "could stay (CONTINUED ON LIC9099-C)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Deborah Mullen
LICENSING EVALUATOR NAME: Tricia Danielson
LICENSING EVALUATOR SIGNATURE:

DATE: 02/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2023
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-20230131104737
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: AFFIRMATIVE'S ELITE HOME
FACILITY NUMBER: 374604137
VISIT DATE: 02/16/2023
NARRATIVE
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(CONTINUED FROM LIC9099)
out until the end or flu season, end of March" in order to prevent R1 from getting sick and causing the other residents to become sick as well. LIC Haragos also provided a written statement attesting to her proposal to R1. Interviews conducted and records reviewed also revealed on December 3, 2022, LIC Haragos asked members of R1's family if “they could possibly keep R1 home from PACE through the flu season which would be till the end of March”. There was no evidence found that R1 was prohibited from boarding the day program bus. Review of video footage of the day R1 moved from the facility revealed residents were in the dining room for lunch at the time of R1's departure however, there was no effort made by R1's family to take R1 into the dining room to say goodbye. Based on LPA’s observations, interviews conducted, and records reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California Code of Regulations (Title 22, Division 6, Chapter 8), is being cited on the attached LIC 9099 D.
An exit interview was conducted and a copy of this report was provided along with Appeal Rights and LIC811- Confidential Names list.
SUPERVISORS NAME: Deborah Mullen
LICENSING EVALUATOR NAME: Tricia Danielson
LICENSING EVALUATOR SIGNATURE:

DATE: 02/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3
Control Number 18-AS-20230131104737
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: AFFIRMATIVE'S ELITE HOME
FACILITY NUMBER: 374604137
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/16/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
02/17/2023
Section Cited
CCR
87468.2
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Additional Personal Rights of Residents in Privately Operated Facilities-(a)In addition to...rights listed in Section 87468.1, residents in...residential care facilities for the elderly shall have the following personal rights:(3)To be encouraged and assisted in exercising their rights...as residents of the facility... be free from interference...in exercising their
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As discussed with Administrator Haragos, the facility will submit a written statement of understanding of the regulation cited and the importance of maintaining the personal rights of all residents in care. POC to be submitted to LPA by due date of 2/17/2023.
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rights. This requirement was not met as evidenced by: LIC did not ensure the personal rights of R1 were maintained. Based on interviews and records reviewed, LIC interfered with R1's decision to attend their day program. This poses an immediate personal rights risk to residents in care.
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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: Deborah Mullen
LICENSING EVALUATOR NAME: Tricia Danielson
LICENSING EVALUATOR SIGNATURE:

DATE: 02/16/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3