331880711-10-25-2023-18-AS-MVAO-CWYVRG-20231026163955

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 331880711
Report Date: 07/16/2020
Date Signed: 10/25/2023 04:28:39 PM

Unsubstantiated

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
05/26/2020 and conducted by Evaluator Yolanda Bejarano

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20200526152138

FACILITY NAME:	AVALON RANCH RESIDENTIAL FACILITY		FACILITY NUMBER:	331880711
ADMINISTRATOR:	WALKER, DANA		FACILITY TYPE:	735
ADDRESS:	1521 AVILA DRIVE		TELEPHONE:	(951) 796-7623
CITY:	PERRIS	STATE: CA	ZIP CODE:	92571
CAPACITY:	4	CENSUS: 1	DATE:	07/16/2020
		UNANNOUNCED	TIME BEGAN:	03:17 PM
MET WITH:	Aide Walker		TIME COMPLETED:	03:18 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff mishandled resident's medication.

Staff did not provide comfortable temperatures for resident

Resident not awarded privacy

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Yolanda Bejarano contacted the facility via telephone to deliver findings for the above allegation(s) via telephone due to COVID-19. LPA explained the purpose of the call and the finding to administrator Aide Walker.

Allegation: "Staff mishandled resident's medication". During the investigation LPA interviewed administrator who stated that S2 informed her that R1 was saying that the medication was mishandled and the incorrect medication was put in the cup. S2 stated that day R1 was demanding and inpatient as I assisted R2 another resident with mediation that requires more time. During that time R1 grabbed the wrong cup thinking it was theirs since both cups have names and start with the letter "A". I deny giving the wrong medication and informed the administrator of the incident. Based on the interviews obtained the allegation is UNSUBSTANTIATED. An UNSUBSTANTIATED allegation means 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.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Yolanda Bejarano
LICENSING EVALUATOR SIGNATURE:	DATE: 07/16/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2020

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-20200526152138

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: AVALON RANCH RESIDENTIAL FACILITY	FACILITY NUMBER: 331880711
	VISIT DATE: 07/16/2020

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Allegation: "Staff did not provide comfortable temperatures for resident". During the investigation LPA interviewed S1 who stated the carpets in the upstairs bedrooms and hallways were cleaned on Thursday, May 27, 2020 around 10 am. Arrangements were made for the residents to stay down stairs. All the windows were open and fans were set-up for air circulation. The room temperature was maybe 80 degrees and all fans were blowing for comfort. R1 had his own fan facing him the entire time. R2 indicated it was warm but the windows were open and there were fans blowing. R3 was not available to interview. Staff indicated
Based on interviews obtained the allegation of staff did not provide comfortable temperatures for resident is UNSUBSTANTIATED. An UNSUBSTANTIATED allegation means 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.

Allegation: "Resident not awarded privacy". S1 stated R1 does not care to do the bed, clean the room, and the cat box. I had two (2) staff clean up R1's room and it took over three hours. I asked the staff to take a photo to show me the room. The photo was taken from outside the door for privacy. This is the only reason why the photo was taken to show R1 the room is clean. Based on the interviews obtained the allegation is UNSUBSTANTIATED. An UNSUBSTANTIATED allegation means 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.

An exit interview was conducted with Adie Walker via telephone and a copy of this report was provided *via email for signature. Report with facility representative signature was obtained. *via email and receipt of report confirmed.

SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Yolanda Bejarano
LICENSING EVALUATOR SIGNATURE:	DATE: 07/16/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2020

LIC9099 (FAS) - (06/04)

Page: 2 of 2