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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331880616
Report Date: 07/29/2024
Date Signed: 07/29/2024 01:55:24 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
01/22/2024 and conducted by Evaluator Kathleen Banrasavong
COMPLAINT CONTROL NUMBER: 18-AS-20240122145635
FACILITY NAME:ANNA CARE LLCFACILITY NUMBER:
331880616
ADMINISTRATOR:BLANCAFLOR, ANNALISAFACILITY TYPE:
740
ADDRESS:26461 RIDGEMOOR RDTELEPHONE:
(951) 309-1622
CITY:SUN CITYSTATE: CAZIP CODE:
92586
CAPACITY:6CENSUS: 4DATE:
07/29/2024
UNANNOUNCEDTIME BEGAN:
01:20 PM
MET WITH:Caregiver, April Ann ReyesTIME COMPLETED:
02:10 PM
ALLEGATION(S):
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Staff did not administer resident's medications as prescribed
INVESTIGATION FINDINGS:
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On 01/22/2024, Community Care Licensing received a complaint alleging Staff did not administer resident’s medication as prescribed. It was reported that the facility staff did not administrator the R1’s medications as prescribed. In regards to the allegation that the Staff did not administer resident's medications as prescribed. It was reported that the facility did not give medications to the R1 and R1’s medication was found sitting on the desk. During the LPA’s records review and observations, the facility does not keep a record such as a Medications log of when the medications where distributed to the residents. LPA interviewed the Administrator and staff members, who stated they know when to give medications to their residents and base this off of reading the doctor’s order and when breakfast, lunch and dinner are given.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Jazmond D HarrisTELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Kathleen BanrasavongTELEPHONE: 951-622-3619
LICENSING EVALUATOR SIGNATURE:

DATE: 07/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2024
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-20240122145635
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: ANNA CARE LLC
FACILITY NUMBER: 331880616
VISIT DATE: 07/29/2024
NARRATIVE
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The residents will get their medications as a routine before or after they eat their meals. LPA was unable to interview R1 due to R1’s passing. The other residents interviewed indicted no issues with receiving their medications on time. LPA reviewed the Centrally Stored Medication Logs for the residents. This allegation is unsubstantiated. Additional interviews could not provide any information to corroborate or refute the allegation. Therefore, due to insufficient information, this allegation is deemed unsubstantiated at this time.

Based on the LPA’s observation, interviews conducted and record review, the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur. Therefore, the allegations are unsubstantiated.

An exit interview was conducted, and a copy of this report, was discussed with and provided to the Caregiver, April Ann Reyes.

SUPERVISOR'S NAME: Jazmond D HarrisTELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Kathleen BanrasavongTELEPHONE: 951-622-3619
LICENSING EVALUATOR SIGNATURE:

DATE: 07/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2