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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331880838
Report Date: 02/28/2023
Date Signed: 02/28/2023 02:16:03 PM

Substantiated


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
, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/23/2023 and conducted by Evaluator Javier Prieto
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20230223165108
FACILITY NAME:EMK RESIDENTIAL CARE FOR ELDERLYFACILITY NUMBER:
331880838
ADMINISTRATOR:PANALIGAN, MARILOUFACILITY TYPE:
740
ADDRESS:7750 BOLERO DRIVETELEPHONE:
(951) 332-0558
CITY:RIVERSIDESTATE: CAZIP CODE:
92509
CAPACITY:6CENSUS: 6DATE:
02/28/2023
UNANNOUNCEDTIME BEGAN:
01:25 PM
MET WITH:Staff Marineth Reyes and Henry ReyesTIME COMPLETED:
02:20 PM
ALLEGATION(S):
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Facility does not have an Administrator.
Facility not follow reporting requirements as regulated.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Javier Prieto arrived to the facility to initiate a complaint investigation regarding the above-mentioned allegations. LPA met with staff Marineth Reyes and Henry Reyes. There was not administrator at the facility during time of visit, with designated administrator qualified to perform the duties of an administrator for approximately 30 days prior to visit. Review of licensing records show that the faciity has not reported any incidents occuring at the facility since June 2022. LPA observed resident #1 (R1) with an injury with no record of R1 visiting the hospital for that injury.

Based on LPA observations, interviews which were conducted and records review, the preponderance of evidence standard has been met. Therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division) are being cited on the attached LIC 9099D).
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Javier PrietoTELEPHONE: 951-217-3135
LICENSING EVALUATOR SIGNATURE:

DATE: 02/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/28/2023
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 56-AS-20230223165108
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
, CA 92507

FACILITY NAME: EMK RESIDENTIAL CARE FOR ELDERLY
FACILITY NUMBER: 331880838
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/28/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/07/2023
Section Cited
CCR
87405
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Administrator - Qualifications and Duties
All facilities shall have a qualified and currently certified administrator. When the administrator is not in the facility, there shall be coverage by a designated substitute who shall have qualifications adequate to be responsible and accountable for management
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Administrator to designate qualified administrator documentation to LPA by POC date and shall include that staff in their LIC 500 to by submitted to LPA by POC date
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This was not met as evidenced by: LPA arriving to the facility with no qualified administrator for approximately 30 days.
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Type B
03/07/2023
Section Cited
CCR
87211(a)(1)
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Reporting requirements
Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following:A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence
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Administrator to submit declaration that reporting requirements will be met as well as previous incidents occurring at the facility since June 2022. This to be submitted to LPA by POC date.
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This was not met as evidenced by; LPA observed resident #1 with an injury. CCL records reviewed to show that no incident report as been submitted of this injury or any other occurrence at the facility since June 2022
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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: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Javier PrietoTELEPHONE: 951-217-3135
LICENSING EVALUATOR SIGNATURE:

DATE: 02/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/28/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2