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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331800063
Report Date: 09/19/2023
Date Signed: 09/19/2023 11:51:07 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/19/2020 and conducted by Evaluator Javina George
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20200619102700
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: 90DATE:
09/19/2023
UNANNOUNCEDTIME BEGAN:
11:02 AM
MET WITH:Grirselda Garcia, Exectuive DirectorTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Staff did not administer pain medication as prescribed.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Javina George arrived unannounced at the facility to deliver findings for the allegation(s) listed above. LPA met with Griselda Garcia, Executive Director and explained the purpose of the visit as well as the elements of the allegations. The allegation(s) were investigated by the department. The investigation consisted of observation, interviews and record review.

LPA reviewed the Medical Authorization form (MAR) an observed the following. On June 2020 Resident #1 (R1) was prescribed Hydrocodone-Acetaminophen, Naloxene (Narcan) and Risperdal (anti-psychotic). The hydrocodone was prescribed as needed due to R1 sustaining a fracture of their Humerus (upper arm) bone on 6/12/21. Per the June 2020 MAR, R1 was not given their Risperdal on 6/18/21 at 5pm. Regarding to the PRN of Hydrocodone Acetaminophen, the MAR revealed that R1 was given their PRN 6/14/20-6/24/20, and then again on 6/28/20-6/30/20. However; there was no pain medication given 6/25/20-6/27/20. Additionally, R1 was prescribed Risperdal and it was not given as prescribed, as R1 ***Continued 9099C...
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javina GeorgeTELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:

DATE: 09/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2023
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 5
Control Number 18-AS-20200619102700
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
FACILITY NAME: GARDENS OF RIVERSIDE, THE
FACILITY NUMBER: 331800063
VISIT DATE: 09/19/2023
NARRATIVE
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missed their PM dose on 6/18/20. R1 was unable to be interviewed to confirm whether they had requested their pain medication as they passed away on 8/10/20. Although R1 was unable to be interviewed, review of documentation indicated that the staff did not administer medication as prescribed. Therefore, the allegation of staff did not administer medication as prescribed is SUBSTANTIATED. A finding that the complaint is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met. The facility will be cited for violation of Title 22 Regulations, Section 87465(c), Incidental Medical and Dental Care. This violation poses a health, safety, and/or personal rights risk to clients in care.

An exit interview was conducted, a copy of this report, along with the LIC 9099-D, and appeal rights were provided to Griselda Garcia, Executive Director.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javina GeorgeTELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:

DATE: 09/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5
Control Number 18-AS-20200619102700
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

FACILITY NAME: GARDENS OF RIVERSIDE, THE
FACILITY NUMBER: 331800063
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/19/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/20/2023
Section Cited
CCR
87465C
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87465 Incidental Medical and Dental (c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (2)Once ordered by the physician the medication is given according to the physician's directions.
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The Licensee agrees to conduct an inservice on medication administration. Proof of POC is to be submitted by 5om on the due date indicated to the department.
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Based on observation, interview, and record review, this requirement is not met as evidenced by: The licensee did not give medications as prescribed on 1 out of 1 times, this poses an immediate health safety and personal rights risk to persons in care.

The licensee agrees to conduct a medication administration in-service. Proof is to be submitted to the department by 5pm on the due date indicated.
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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 EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javina GeorgeTELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:

DATE: 09/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/19/2020 and conducted by Evaluator Javina George
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20200619102700

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: 90DATE:
09/19/2023
UNANNOUNCEDTIME BEGAN:
11:02 AM
MET WITH:Grirselda Garcia, Exectuive DirectorTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Resident sustained unexplained cuts and bruises while in care.
Facility staff neglected resident resulting in an injury (fracture).
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Javina George arrived unannounced at the facility to deliver findings for the allegation(s) listed above. LPA met with Griselda Garcia, Executive Director and explained the purpose of the visit as well as the elements of the allegations. The allegation(s) were investigated by the department. The investigation consisted of observation, interviews and record review.

Per interview and documentation review, R1 sustained a fractured Humerus (upper arm) bone, due to an unwitnessed fall. LPA attempted to interview multiple sources that had knowledge of the incident, however, LPA could not confirm that R1 had any types of cuts or bruises while at the facility. The facility submitted a Serious Incident Report (SIR) reporting that R1 needed to have their cast replaced on June 15, 2020 and it was noted by medical personnel that there were no other injuries observed. LPA did not review any documentation that confirmed the resident had any cuts or bruises, other than the cast mentioned.
*** Continued on 9099C...
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javina GeorgeTELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:

DATE: 09/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 18-AS-20200619102700
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
FACILITY NAME: GARDENS OF RIVERSIDE, THE
FACILITY NUMBER: 331800063
VISIT DATE: 09/19/2023
NARRATIVE
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Based on interviews and record review, the allegation that resident sustained unexplained cuts and bruises while in care, may have occurred, however is not supported at this time. Therefore, the allegation that resident sustained unexplained cuts and bruises while in care is UNSUBSTANTIATED at this time.


Allegation: Facility staff neglected resident resulting in an injury (fracture). LPA conducted interviews with staff and it was revealed that R1 sustained a fall on June 12, 2020 while R1 was in a private room. A review of the facility employment schedule revealed that on June 12, 2020, there were five staff on duty at the time of R1's unwitnessed fall. Interviews and record reviews conducted by the department revealed that facility staff followed proper fall precautions when R1 fell, which included, contacting 911 and R1’s responsible party. LPA was unable corroborate that facility staff neglected resident resulting in an injury (fracture). Based on interviews and record review, the allegation that facility staff neglected resident resulting in an injury, may have occurred, however is not supported at this time. Therefore, the allegation is UNSUBSTANTIATED at this time.

An exit interview was conducted, a copy of this report and appeal rights were provided to Executive Director, Griselda Garcia.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javina GeorgeTELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:

DATE: 09/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 5