331800063-1-31-2023-56-AS-EMAN-CNUUYC-20230208145941

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 331800063
Report Date: 01/31/2023
Date Signed: 01/31/2023 11:03:44 AM

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
09/02/2022 and conducted by Evaluator Melody Brown

PUBLIC

COMPLAINT CONTROL NUMBER: 56-AS-20220902161328

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: 89	DATE:	01/31/2023
		ANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Executive Director Stephanie Oden and Resident Care Director Jessica Padron		TIME COMPLETED:	11:30 AM

ALLEGATION(S):

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Resident sustained injury while in care due to lack of supervision

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Melody Brown met with Executive Director Stephanie Oden and Resident Care Director Jessica Padron at Community Care Licensing Division (CCLD) Adult and Senior Care (ASC) Regional Office 01/31/2023 at 10:30 AM to deliver the findings of the above allegation. LPA Brown explained the purpose of the requested Office Visit. The investigation consisted of observation, interviews and a review of pertinent documentations.

The investigation was conducted by LPA Brown. The investigation consisted of file review and interviews with relevant parties. The allegation indicates Resident 1 (R1) sustained injury while in care due to lack of supervision. Evidence showed that R1 sustained bruise while in care last 08/29/2022. However, evidence also showed that the facility had sufficient number of staff monitoring and supervising all residents at the facility in reference to the facility’s Personnel Summary Report (LIC500).

***Continuation in LIC9099C***

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody Brown	TELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:	DATE: 01/31/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 56-AS-20220902161328

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: 01/31/2023

NARRATIVE

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Staff interviews indicated that they are assisting and monitoring all residents last 08/29/2022 as they are getting ready for breakfast and while they were assisting other residents, they just heard R1 shouted "help" and staff indicated it happened so fast and they immediately went to check on R1. Staff also added that they found R2 at R1's room. In addition, LPA Brown observed that the facility ensured that R1 was medically assessed, the facility reported the incident to R1’s Physician, Responsible Party, and other state agencies. Moreover, staff interviews revealed that the facility staff reported the incident last 08/29/2022 to R2's Physician, Responsible Party and other state agencies and shortly after the incident, staffs reported that Resident 2 (R2) was provided one on one (1:1) Aid to appropriately monitor R2’s aggressive behavior. LPA Brown reviewed Personnel Summary Report (LIC500) and staff work schedule and it showed sufficient number of staff working at the facility to provide care and supervision to residents in care. LPA Brown observed that five (5)staffs works at Magnolia Building that time and three (3) staffs were assigned to Jasmin Building. Administrator Oden reported during the Office Visit 01/31/2023 that all staff are responsible on monitoring R2 due to R2's aggressive behavior. Administrator Oden also said that it's a team effort and all staff are aware that R2 was put on frequent checks which is every 15-30 minutes since 07/2022.

Based on interviews and records review, the allegation Resident sustained injury while in care due to lack of supervision is UNSUBSTANTIATED. A finding of unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur.

An exit interview was conducted, where this report (LIC9099) was discussed and provided to Executive Director Stephanie Oden and Resident Care Director Jessica Padron.

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody Brown	TELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:	DATE: 01/31/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2023

LIC9099 (FAS) - (06/04)

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