331800063-3-30-2022-18-AS-EMAN-CDLS5Y-20220418133507

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 331800063
Report Date: 03/30/2022
Date Signed: 03/30/2022 02:29:15 PM

Unsubstantiated

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
, CA 92507

This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/28/2022 and conducted by Evaluator Stephanie Williams

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20220128145703

FACILITY NAME:	GARDENS OF RIVERSIDE, THE		FACILITY NUMBER:	331800063
ADMINISTRATOR:	STEPHANIE ODEN		FACILITY TYPE:	740
ADDRESS:	10849 ARLINGTON AVE		TELEPHONE:	(951) 637-8844
CITY:	RIVERSIDE	STATE: CA	ZIP CODE:	92505
CAPACITY:	98	CENSUS: 83	DATE:	03/30/2022
		UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Stephanie Oden		TIME COMPLETED:	02:40 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility staff physically abused residents
Facility staff verbally abused residents
Facility staff not meeting incontinence care needs of residents
Facility staff did not retrieve timely medical care for resident

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Stephanie Williams made an unannounced visit to the facility in order to initiate a complaint investigation into the above allegations. LPA Williams identified herself to Administrator, Stephanie Oden, who was also informed of the purpose of the visit. The investigation consisted of direct observations, records review, and interviews with staff and residents.

LPA Williams attempted to interview several residents including, Resident #1 (R1), Resident #2 (R2), Resident #3 (R3), and Resident #4 (R4); however, LPA Williams was unable to retrieve consistent statements from all attempted interviews due to residents’ memory capabilities. The facility is a memory care facility; consequently, all resident's have some form of cognitive impairment.

In regards to allegation #1, LPA Williams did not discover any evidence which would prove that facility staff did in fact, physically abused the residents. LPA Williams interviewed Staff #1 (S1), Staff #2 (S2), and Staff #3 (S3), who all denied witnessing that residents were being physically abused or mishandled inappropriately.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Stephanie Williams	TELEPHONE: (951) 201-0159
LICENSING EVALUATOR SIGNATURE:	DATE: 03/30/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2022

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-20220128145703

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
, CA 92507

FACILITY NAME: GARDENS OF RIVERSIDE, THE	FACILITY NUMBER: 331800063
	VISIT DATE: 03/30/2022

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

S1 stated that there were concerns regarding mistreatment of the residents by Staff #4 (S4) and Staff #5 (S5), who were contracted through a temp agency, and an internal investigation was conducted. S1 stated that the allegation could not be proved; however, those staff members are no longer working at the facility. S2 stated that they “heard” from other staff members that S4 may have been physically aggressive with some residents but denied witnessing such incidence. S1 and S2 also both denied observing any injuries/bruises on resident’s indicative of physical abuse. LPA Williams attempted to contact S4 and S5 on several occasions but was unsuccessful.

In regards to allegation #2, LPA Williams did not discover any evidence which would prove that facility staff did in fact, verbally abused the residents. LPA Williams interviewed S1, S2, and S3, who all denied having knowledge or witnessing staff members being verbally abusive towards residents. LPA Williams attempted to contact S4 and S5 on several occasions but was unsuccessful.

In regards to allegation #3, LPA Williams did not discover any evidence which would prove that facility staff did not, in fact, meet the incontinence care needs of the residents. LPA Williams interviewed S1 and S2, who stated that facility protocol is to change/check residents for incontinence every two hours or as needed for those who require higher care. S1 and S2 denied that facility staff is not meeting incontinence care needs of the residents. S1 and S2 stated that facility staff is following facility protocol regarding incontinence care. LPA Williams also interviewed S3 who denied facility staff is not meeting the incontinence care needs of the residents. S3 stated that from what they have observed, facility staff are constantly changing residents’ diapers.

In regards to allegation #3, LPA Williams did not discover any evidence which would prove that facility staff did not, in fact, retrieve timely medical care for resident. LPA Williams interviewed S1 and S2 who stated that R1's medical provider was made aware of R1's change in condition and subsequently contacted emergency services. LPA Williams reviewed R1's medical records which indicated that R1 was taken to the hospital to address change of condition observed by facility staff. LPA Williams interviewed S1 and S2 regarding the injuries R2 had sustained from an altercation with another resident. S1 and S2 both stated that R2 was assessed and facility staff determined that they would call emergency services for R2. S2 stated that there was a delay in sending R2 via ambulance as the fire department who responded stated that there is no ambulance readily available. S2 did state that R2 was being treated and assessed by the fire department/paramedic until an ambulance was available to transport R2. LPA Williams reviewed R2's medical

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Stephanie Williams	TELEPHONE: (951) 201-0159
LICENSING EVALUATOR SIGNATURE:	DATE: 03/30/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 18-AS-20220128145703

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
, CA 92507

FACILITY NAME: GARDENS OF RIVERSIDE, THE	FACILITY NUMBER: 331800063
	VISIT DATE: 03/30/2022

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

records which indicated that R2 was taken to the emergency room on the same day which the incidence occurred.

Based on evidence obtained during today’s visit, LPA has determined that the above allegations are UNSUBSTANTIATED; meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur.

An exit interview was conducted where this report was discussed (LIC 9099) and a copy was provided to the Administrator at the conclusion of the visit.

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Stephanie Williams	TELEPHONE: (951) 201-0159
LICENSING EVALUATOR SIGNATURE:	DATE: 03/30/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2022

LIC9099 (FAS) - (06/04)

Page: 3 of 3