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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374603683
Report Date: 04/27/2023
Date Signed: 04/27/2023 12:13:52 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
04/19/2023 and conducted by Evaluator Janira Arreola
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20230419160659
FACILITY NAME:BREEZE HILL CAREFACILITY NUMBER:
374603683
ADMINISTRATOR:SMILJA MILOSAVLJEVICFACILITY TYPE:
740
ADDRESS:799 MARSOPA DRIVETELEPHONE:
(760) 631-0267
CITY:VISTASTATE: CAZIP CODE:
92081
CAPACITY:6CENSUS: 5DATE:
04/27/2023
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Licensee,Smilja MilosavljevicTIME COMPLETED:
12:20 PM
ALLEGATION(S):
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Staff using seatbelt restraint blocking resident from standing up
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Janira Arreola and Sara Martinez, conducted an unannounced visit to the facility in order to investigate the above allegations. LPA met with Licensee,Smilja Milosavljevic who was informed of the purpose of the visit.

Regarding the allegation, the facility used a seatbelt restraint on a resident, Resident #1 (R1). It was alleged that on 3/2/2023, R1 appeared to be “uncomfortable”, and attempted to stand from their wheelchair with the seatbelt preventing them from doing so. It was also alleged that staff stated that R1 did not “like” using a high-back wheelchair.


Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE:

DATE: 04/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/27/2023
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-20230419160659
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: BREEZE HILL CARE
FACILITY NUMBER: 374603683
VISIT DATE: 04/27/2023
NARRATIVE
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During the visit, LPA conducted interviews, documented observations, and conducted records reviews. LPAs interviewed staff who stated that R1 was using a belt in the past due to R1 having falls at the facility, but are no longer using the belt. LPAs observed R1 in the dining table and did not observe a belt on R1's wheelchair. Staff interviewed stated that the belt had not been prescribed by a physician. LPAs observed R1 had their hands on the grab bars of the wheelchair, appeared to be trying to get up from the wheelchair.

Therefore, the allegation that R1 was using a belt preventing them from getting up from their wheelchair is substantiated. A finding of substantiated means the preponderance of the evidence standard has been met.

An exit interview was conducted with the Licensee,Smilja Milosavljevic, where this report along with LIC9099-D page and appeal rights were reviewed and provided to them.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE:

DATE: 04/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/27/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 18-AS-20230419160659
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: BREEZE HILL CARE
FACILITY NUMBER: 374603683
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/27/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/28/2023
Section Cited
CCR
87608(a)(3)
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87608 Postural Supports (a) ...Postural supports may be used under the following conditions. (3) A written order from a physician indicating the need for the postural support shall be maintained in the resident’s record... This requirement was not met as evidenced by:
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The licensee agreed to send the LPA a written and signed statement stating how they plan to deal with resident's conditions without the use of a restraint.
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Based on interview, record review, and observation it was found that R1 was using a belt in R1's wheelchair. Thsi poses an immediate personal rights, health or saftey risk for 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: Joel Esquivel
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE:

DATE: 04/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/27/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3