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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331800063
Report Date: 06/08/2020
Date Signed: 06/08/2020 04:06:07 PM



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
01/06/2020 and conducted by Evaluator Stephanie Williams
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20200106170819
FACILITY NAME:GARDENS OF RIVERSIDE, THEFACILITY NUMBER:
331800063
ADMINISTRATOR:STEPHANIE ODENFACILITY TYPE:
740
ADDRESS:10849 ARLINGTON AVETELEPHONE:
(951) 637-8844
CITY:RIVERSIDESTATE: CAZIP CODE:
92505
CAPACITY:98CENSUS: 63DATE:
06/08/2020
UNANNOUNCEDTIME BEGAN:
03:10 PM
MET WITH:Shannon GordonTIME COMPLETED:
04:30 PM
ALLEGATION(S):
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Resident sustained multiple fractures while in care

INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Stephanie Williams contacted the facility to deliver findings for the allegation listed above via telephone due to the COVID-19 pandemic. LPA spoke with Resident Service Director, Shannon Gordon, and explained the purpose of today's call.

The department investigation included file review, interviews with staff/residents/witnesses, and collecting pertinent documentation and records. Based on evidence collected during the investigation, Resident #1 (R1) experienced a fall. R1's medical records were obtained and reviewed; they did not indicate that R1's fall was a result of neglect by the facility. Department staff interviewed Staff #1 (S1) who indicated that they observed R1 “throwing” themselves out of the wheelchair and onto the floor, which resulted in the fractures.

This agency has investigated the complaint alleging that R1 sustained multiple fractures while in care. We have found that the complaint was UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. We have therefore dismissed the complaint.
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 248-0337
LICENSING EVALUATOR NAME: Stephanie WilliamsTELEPHONE: (951) 248-0317
LICENSING EVALUATOR SIGNATURE:

DATE: 06/08/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/08/2020
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-20200106170819
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: GARDENS OF RIVERSIDE, THE
FACILITY NUMBER: 331800063
VISIT DATE: 06/08/2020
NARRATIVE
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An exit interview was conducted where this report was discussed via telephone. A copy was provided to Gordon via email.
SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 248-0337
LICENSING EVALUATOR NAME: Stephanie WilliamsTELEPHONE: (951) 248-0317
LICENSING EVALUATOR SIGNATURE:

DATE: 06/08/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/08/2020
LIC9099 (FAS) - (06/04)
Page: 2 of 2