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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374604135
Report Date: 02/09/2023
Date Signed: 02/09/2023 01:59:55 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
02/06/2023 and conducted by Evaluator Janira Arreola
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20230206110845
FACILITY NAME:SHADOWRIDGEFACILITY NUMBER:
374604135
ADMINISTRATOR:BEATRICE BRACAMONTEFACILITY TYPE:
740
ADDRESS:2354 WATSON WAYTELEPHONE:
(760) 295-3888
CITY:VISTASTATE: CAZIP CODE:
92081
CAPACITY:48CENSUS: 34DATE:
02/09/2023
UNANNOUNCEDTIME BEGAN:
12:40 PM
MET WITH:Executive Direcotr Levina DuboseTIME COMPLETED:
02:15 PM
ALLEGATION(S):
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Residents were not provided with hot water for showers
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Janira Arreola and Javina George, conducted an unannounced vivist to the facility in order to initate an investigation into the above allegatios. The LPAs met with Levina Dubose who was informed of the purpose of the visit.

Cocerning allegation "Residents were not provided hot water for showers", it was alleged that the facility did not have running hot water to provide residents for showers. It was alleged that this had been going on for a period of (2) weeks. LPAs conducted a tour of the facility and observed the facility broiler room, where staff stated a flood had occured and damadged the water broiler. LPAs conducted a tour of the facility detached "cottage" area where LPAs observed running hot water at 113.3F. This cottage includes a bathroom that has a shower with hot water, and the facility laundry room.

LPAs conducted interviews with staff and residents and found that the claim of the facility being without water for (2) weeks was corroborated.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE:

DATE: 02/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2023
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-20230206110845
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: SHADOWRIDGE
FACILITY NUMBER: 374604135
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/09/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/10/2023
Section Cited
CCR
87303(e)(2)
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87303 Maintenance and Operation (e) Water supplies and plumbing fixtures shall be maintained as follows:(2) Faucets used by residents for personal care such... shall deliver hot water... This requirment was not met as evidenced by:
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The licensee agreed to make a facility plan on how they plan on mitigating the situation and accomidating the showers for all residents. This shall be submitted and implemented by the POC due date.
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Based on interview, record review, and observation, it was found that the facility does not have hot water that can accomidate all resident hygiene needs. This poses an immediate personal rights, health or saftey 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.
SUPERVISOR'S NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE:

DATE: 02/09/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 18-AS-20230206110845
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: SHADOWRIDGE
FACILITY NUMBER: 374604135
VISIT DATE: 02/09/2023
NARRATIVE
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 Interviews also revealed that facility residents had not been informed of the facility plan for accommodating the resident's showers. It was also found that some residents have been taken to their family's homes to take showers, and some residents have been able to take a shower in the "cottage" area. LPA reviewed the facility documented invoices where it was observed that the facility had a plumbing issue with water back flow that was inspected on 1/28/2023. LPA spoke with the administrator who stated that the new broiler will be installed in the facility in the next (2) days. Meanwhile, the administrator stated that residents in wheelchairs, which were observed to be 10 out of the 34 will be bused to facility Vista Gardens #374604198.

Based on interviews, record review, and observations, it was found that the allegation is substantiated. A finding of substantiated means that the preponderance of the evidence standard has been met.

An exit interview was conducted, where this report along with deficiency page and plan of correction where reviewed and provided to with executive director, Levina Dubose.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE:

DATE: 02/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3