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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331800063
Report Date: 06/26/2024
Date Signed: 06/26/2024 08:56:05 AM


Document Has Been Signed on 06/26/2024 08:56 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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, THEFACILITY NUMBER:
331800063
ADMINISTRATOR:GRISELDA T. GARCIAFACILITY TYPE:
740
ADDRESS:10849 ARLINGTON AVETELEPHONE:
(951) 637-8844
CITY:RIVERSIDESTATE: CAZIP CODE:
92505
CAPACITY:98CENSUS: 80DATE:
06/26/2024
TYPE OF VISIT:Case Management - DeficienciesANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Executive Director Griselda Garcia TIME COMPLETED:
09:00 AM
NARRATIVE
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On 06/26/2024 at 08:00 AM, Licensing Program Analyst (LPA) Melody Brown met with Executive Director Griselda Garcia at Community Care Licensing Division (CCLD) Adult and Senior Care (ASC) Regional Office to initiate a Case Management Office Meeting. LPA Brown explained the purpose of the requested Office Meeting. The investigation consisted of observation, interviews, and a review of pertinent documentation.

Through the information gathered during the investigation, it was confirmed by documents review and staffs interviews that the facility did not appropriately report to R2's Primary Care Physician (PCP) their observation on R2's sexual behavior history of inappropriately touching another resident since 07/06/2022, followed by another incident on 07/19/2022 and 08/06/2022 to appropriately address the issue when R2's PCP completed R2's Physician Report on 03/05/2023. Then, Community Care Licensing Department (CCLD) received an Unusual Incident/Injury Report from the facility indicating another incident of R2's inappropriate sexual behavior that occurred on 10/21/2023 with another female resident. LPA Brown explained to ED Garcia that deficiency will be issued as this pose immediate health, safety and personal rights risk to residents in care. ED Garcia verbalized understanding. Furthermore, per documents review, LPA Brown observed no reappraisal conducted on an ongoing basis by facility staff as required due to R2's dementia diagnosis. Deficiencies will be issued.

An exit interview was conducted where this report (LIC809), LIC80D, and Appeal Rights were discussed and provided to Executive Director Griselda Garcia.
SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:
DATE: 06/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/26/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/26/2024 08:56 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/26/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/27/2024
Section Cited
CCR
87466

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87466 Observation of the Resident: The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs....This requirement is not met as evidenced by:
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Licensee stated to train all staff on CCR 87466 and submit proof of all staff training log to LPA Brown on Plan of Correction due date.
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Based on interviews and records review, the Licensee did not comply with section cited above by not regularly observing R2’s change of condition indicating R2's sexual behavior of inappropriately touching other resident that started on 07/19/2022 followed by another incident on 07/19/2022 and 08/06/2022 and the facility did not report R2’s change of condition to R2’s physician as evidenced on R2's most recent Physician Report with signature date 03/05/2023, which poses immediate health, safety and personal rights risks to residents in care.
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Type B
07/08/2024
Section Cited
CCR87705(c)(6)

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87705 Care of Persons with Dementia (c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (6) Appraisals are conducted on an ongoing basis pursuant to Section 87463, Reappraisals. This requirement is not met as evidenced by:
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Licensee stated to train all staff on CCR 87705(c)(6) and submit proof of all staff training log to LPA Brown on POC due date.
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Based on interviews and records review, the Licensee did not comply with section cited above by not conducting the required ongoing reappraisal to R2 due to R2's dementia diagnosis and reported changed of condition/behavior which pose potential health, safety, and personal rights risk to resident 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.
SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:
DATE: 06/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/26/2024
LIC809 (FAS) - (06/04)
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