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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331880508
Report Date: 05/04/2026
Date Signed: 05/04/2026 12:37:02 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 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
12/04/2023 and conducted by Evaluator Deborah Lee
COMPLAINT CONTROL NUMBER: 18-AS-20231204123205
FACILITY NAME:EMPATHYFACILITY NUMBER:
331880508
ADMINISTRATOR:BANSODE, HEMALATAFACILITY TYPE:
740
ADDRESS:17312 RIVA RIDGETELEPHONE:
(951) 323-0536
CITY:MORENO VALLEYSTATE: CAZIP CODE:
92555
CAPACITY:6CENSUS: 0DATE:
05/04/2026
UNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Hemalata Bansode TIME COMPLETED:
12:30 PM
ALLEGATION(S):
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Resident is not receiving medication as prescribed.
INVESTIGATION FINDINGS:
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On May 4, 2026, the Department of Social Services staff conducted an unannounced visit to this facility to continue investigation of the above allegation and to deliver findings. The Department was met by Licensee Hemalata Bansode and the purpose of the visit was explained.

Investigation consisted of the following:
On December 11, 2023, the Department conducted an unannounced initial visit to the facility to investigate the complaint allegation mentioned above and it was determined that the complaint required further investigation. On December 19, 2023, the department conducted interview with R1.

On April 29, 2026, the department made an attempted visit to conduct subsequent complaint visit and to deliver findings. At 1:00pm, the department arrived at facility, rang doorbell and there was no answer. The department made calls to numbers on file for the facility and there was no answer, The department left voice message for a return call. At approximately 1:26pm the Licensee returned the department's call and informed her that there are currently no residents in placement at the facility.
On May 4, 2026, the Department requested and obtained the following documents: Medication orders (dated: 9/15/2023 ), MAR (dated: Dec 2023 ), Physician’s report (dated 12/11/19), and shift notes (dated 12/3/23)
The department interviewed Administrator (A1), There were no staff nor residents available to interview as there are currently no residents in placement.
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Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Deborah Lee
LICENSING EVALUATOR SIGNATURE:

DATE: 05/04/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2026
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 2
Control Number 18-AS-20231204123205
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: EMPATHY
FACILITY NUMBER: 331880508
VISIT DATE: 05/04/2026
NARRATIVE
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The investigation revealed the following:

Allegation: Resident is not receiving medication as prescribed.

The detail of the complaint alleges that R1 “does not get medication safely and timely”

On May 4, 2026, the department interviewed Administrator/Licensee (A1) who denied allegation stating that medication for all residents are always given as prescribed. According to A1 in some cases when a resident’s blood pressure is at a certain level, then the medication is to be held. Staff held R1’s medication due to her blood pressure being low. Licensee stated that she followed the medical professional’s advice to hold R1’s medication on 12/3/23.

On 12/19/23 the department interviewed R1 regarding the allegation and R1 denied the allegation, stating that “she made sure she got her medications when she was at Empathy.” During the interview, R1 further stated that there was never a time when she did not get her medications.

On May 4, the department reviewed and evaluated the following documents: Medication orders (dated: 9/15/2023 ), MAR (dated: Dec 2023 ), Physician’s report (dated 12/11/19), and shift notes (dated 12/3/23). The documents showed no discrepancies and that the facility followed the medical professional’s order to hold R1’s medication.

Based on the information gathered, there is insufficient evidence to support the allegation mentioned above; 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, therefore the allegation is UNSUBSTANTIATED.

Exit interview conducted with Hemalata Bansode. There were no deficiencies cited during today’s visit. Copy of report provided.

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SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Deborah Lee
LICENSING EVALUATOR SIGNATURE:

DATE: 05/04/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 2