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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331800063
Report Date: 11/03/2020
Date Signed: 11/03/2020 02:13:57 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
06/15/2020 and conducted by Evaluator Robbie Johnson
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20200615164905
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: 79DATE:
11/03/2020
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Shannon Gordon, Resident Service DirectorTIME COMPLETED:
01:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Resident sustained arm fracture due to staff neglect.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Robbie Johnson contacted the facility via telephone due to Covid-19 to deliver findings for the above allegation. LPA met with Shanon Gordon, Resident Service Director and discussed the purpose of today’s visit. The department investigation included file review, interviews with staff/residents/witnesses, and review of pertinent records.

Interviews and record reviews conducted by the department revealed that facility staff followed proper fall precautions when R1 fell. On June 12, 2020, R1 had an unwitnessed fall. R1 was transported to the hospital and diagnosed with a right humerus fracture. R1 was returned to the facility with a cast. Three days later R1 returned to the hospital because the initial cast needed to be replaced. No additional injures were found. Based on the investigation, no supporting evidence was found that indicated that the injury that R1 sustained was due to staff neglect. Therefore, the allegation is 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. A copy of this report was reviewed with and provided to Shannon Gordon.


Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Robbie JohnsonTELEPHONE: (951) 248-0304
LICENSING EVALUATOR SIGNATURE:

DATE: 11/03/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2020
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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