331800063-10-12-2021-18-AS-NBRN-C8ET8G-20211103143020

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 331800063
Report Date: 10/12/2021
Date Signed: 10/12/2021 11:23:33 AM

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
09/21/2020 and conducted by Evaluator Amy Goldenberg

COMPLAINT CONTROL NUMBER: 18-AS-20200921101723

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: 86	DATE:	10/12/2021
		UNANNOUNCED	TIME BEGAN:	10:45 AM
MET WITH:	Stephanie Oden, Executive Director		TIME COMPLETED:	11:45 AM

ALLEGATION(S):

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Questionable death

INVESTIGATION FINDINGS:

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This unannounced visit by Amy Goldenberg, Licensing Program Analyst (LPA), is being conducted to present investigative findings. The Department completed investigation into the death of R1. The investigation included inspection of facility and review of facility records, review of records for R1, review of staff training records, review of facility policies, staff and witness interviews, and review of other pertinent reports and information. Based on the investigation, there is preponderance of evidence to support that facility staff neglected R1. Specifically, it was found that on September 5, 2020, facility staff failed to insure adequate care, supervision, and services to R1 prior to R1 death.

Interviews with staff revealed that on September 5, 2020, the facility experienced a power outage that occurred from approximately 1pm to 5pm. The power was restored in the main building, but not in the outside courtyard. It was reported the temperature was over 110 degrees F on this day.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 248-0339
LICENSING EVALUATOR NAME: Amy Goldenberg	TELEPHONE: (951) 248-0351
LICENSING EVALUATOR SIGNATURE:	DATE: 10/12/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2021

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 18-AS-20200921101723

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
RIVERSIDE, CA 92507

FACILITY NAME: GARDENS OF RIVERSIDE, THE	FACILITY NUMBER: 331800063
	VISIT DATE: 10/12/2021

NARRATIVE

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(S1) reports last observation of (R1) was around 7pm. Prior to that time, R1 was observed outside around 5 pm. Around this time, R1 was provided dinner but it was reported during interviews that it is not known if R1 ate the meal. (S1) reported that (R1) was asked to come inside of the facility, but (R1) refused. (S1) reported that when (R1) refused, (R1) was left outside unsupervised in a courtyard that had no lights. According to records, (R1) had dementia, confusion, disorientation, and an inability to follow instructions or communicate needs. (R1) also did not have the capacity for self-care and required moderate to maximum assistance with feeding. (R1) had at least 2 reported falls prior to death. R1 resided in the memory care building of facility.

At approximately 8 pm on September 5, 2020, (S1) and (S2) went outside to look for (R1). The courtyard was noted as being “very dark.” (R1) was found in the courtyard unresponsive and lying on the ground with wires wrapped around legs. Interviews reveal that (S1) and (S2) did not immediately contact emergency services or render first aid, but instead contacted (S3) for assistance. Interview with (S3) revealed that when she arrived at the courtyard about 5 minutes later, (S3) observed (R1) body to be stiff. (S3) contacted facility management (S4), who instructed (S3) to contact 911. According to records, (S3) contacted 911 about 8:15pm and 911 operator instructed (S3) to perform Cardiopulmonary resuscitation (CPR). Based on interviews and record review, (R1) was deceased upon emergency personnel arrival to the facility at about 8:25 pm. Riverside County Sheriff’s Coroner report determined cause of death to be environmental heat exposure and was ruled an accident.

Department Investigation found thru interviews that residents in memory care building are to be checked every 30 minutes. However, it is not indicated that R1 was checked every 30 minutes on September 5, 2020. Facility staff also reported that R1 was left outside in the courtyard unsupervised for an unknown period of time even though there were no lights to illuminate the area. R1 has previous falls and was found around 8 pm in area described as “very dark.” In addition, facility staff did not immediately contact 911 services, investigation revealed that two additional staff were contacted prior to initiating 911 call. Based on above, allegation that facility staff neglected R1 prior to R1 death is substantiated.

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 248-0339
LICENSING EVALUATOR NAME: Amy Goldenberg	TELEPHONE: (951) 248-0351
LICENSING EVALUATOR SIGNATURE:	DATE: 10/12/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2021

LIC9099 (FAS) - (06/04)

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Control Number 18-AS-20200921101723

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
RIVERSIDE, CA 92507

FACILITY NAME: GARDENS OF RIVERSIDE, THE	FACILITY NUMBER: 331800063
	VISIT DATE: 10/12/2021

NARRATIVE

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Due to the violation that the department determines resulted in the injury, illness, or death of a person in care, an immediate civil penalty of $500 was assessed on 10/12/2021.

Based on the information obtained through review of the records, interviews conducted, and reports obtained this agency has substantiated the complaint allegation as valid and that a violation has occurred based on the preponderance of available evidence.

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 248-0339
LICENSING EVALUATOR NAME: Amy Goldenberg	TELEPHONE: (951) 248-0351
LICENSING EVALUATOR SIGNATURE:	DATE: 10/12/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2021

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 18-AS-20200921101723

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
RIVERSIDE, CA 92507

FACILITY NAME: GARDENS OF RIVERSIDE, THE	FACILITY NUMBER: 331800063
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/12/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 10/13/2021 Section Cited HSC 1569.269(a)(6)	1 2 3 4 5 6 7	Enumerated rights; severability - Residents of residential care facilities for the elderly shall have all of the following rights: To care, supervision, and services that meet their individual needs and are	1 2 3 4 5 6 7	Licensee will read and submit statement of understanding regarding Health and Safety Code 1569.269(a)(6).
	8 9 10 11 12 13 14	delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs.The facility has failed to meet this requirement as evidenced by the lack of supervision provided to (R1) which led to (R1) being left outside unattended for an unknown amount of time.	8 9 10 11 12 13 14	Also, training will be conducted on Enumerated rights with all care staff. Training Log will be submitted to the Department by POC date.
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Nedra Brown	TELEPHONE: (951) 248-0339
LICENSING EVALUATOR NAME: Amy Goldenberg	TELEPHONE: (951) 248-0351
LICENSING EVALUATOR SIGNATURE:	DATE: 10/12/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2021

LIC9099 (FAS) - (06/04)

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