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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331880902
Report Date: 06/20/2023
Date Signed: 06/20/2023 04:32:15 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
RIVERSIDE, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/16/2023 and conducted by Evaluator Javina George
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20230616115956
FACILITY NAME:BUENA VISTA ASSISTED LIVINGFACILITY NUMBER:
331880902
ADMINISTRATOR:GRISELDA GARCIAFACILITY TYPE:
740
ADDRESS:1393 S. BUENA VISTA ST.TELEPHONE:
(951) 658-5160
CITY:HEMETSTATE: CAZIP CODE:
92543
CAPACITY:49CENSUS: 35DATE:
06/20/2023
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Bernadette Best, AdministratorTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Staff are not providing medications as prescribed to resident(s) in care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Javina George made an unannounced visit to the facility to commence a complaint investigation in regards to the allegation listed above. LPA met with Administrator Bernadette Best, Administrator where LPA explained the purpose of the visit and the elements of the allegation.

Regarding the allegation of staff are not providing medications as prescribed to resident(s) in care. It was reported that on or around June 16, 2023, Resident #1 (R1) did not receive their 2:00am medication as prescribed. Per interviews conducted with the Administrator Rene, revealed that the staff had taken both sets to the medication room keys home. A text and phone call were made to retrieve the keys, but was not viewed until 5:30am, resulting in R1 getting the medication late. Based on interviews the allegation of staff are not providing medications as prescribed to resident(s) in care is SUBSTANTIATED. A substantiated finding means that the preponderance of evidence standard has been met; therefore, the above allegation is found to be Substantiated. An exit interview was conducted and a copy of this report and appeal rights were provided to Bernadette Best, Administrator.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Javina George
LICENSING EVALUATOR SIGNATURE:

DATE: 06/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2023
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 4
Control Number 18-AS-20230616115956
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: BUENA VISTA ASSISTED LIVING
FACILITY NUMBER: 331880902
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/20/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/04/2023
Section Cited
CCR
87465(2)(c)
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87465 Incidental Medical and Dental Care:(c) If the resident's physician has stated in writing ...(2) Once ordered by the physician the medication is given according to the physician's directions. Based on observation and interviews this requirement was not met
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The Licensee agrees have an extra set of keys made and issued to the Senior Med Tech and Nurse Consultant, in addition to the set the administrator has. Proof of POC is to be submitted to the department by 5pm on the due date indicated.
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as evidence by: interviews with staff revealed that resident # 1 (R1) was not given their medications as prescribed, as the keys were taken home. This poses a potential health, safety and personal rights risk to the resident in care.
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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.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Javina George
LICENSING EVALUATOR SIGNATURE:

DATE: 06/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 4
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
06/16/2023 and conducted by Evaluator Javina George
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20230616115956

FACILITY NAME:BUENA VISTA ASSISTED LIVINGFACILITY NUMBER:
331880902
ADMINISTRATOR:GRISELDA GARCIAFACILITY TYPE:
740
ADDRESS:1393 S. BUENA VISTA ST.TELEPHONE:
(951) 658-5160
CITY:HEMETSTATE: CAZIP CODE:
92543
CAPACITY:49CENSUS: 35DATE:
06/20/2023
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Bernadette Best, AdministratorTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Staff did not respond to resident's call for assistance in a timely manner.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Javina George made an unannounced visit to the facility to commence a complaint investigation in regards to the allegation listed above. LPA met with Administrator Rene Lorezen-Best where LPA explained the purpose of the visit and the elements of the allegation.

Allegation: Staff did not respond to resident's call for assistance in a timely manner.
It was reported that it takes staff anywhere from an hour to an hour and a half to respond at times after the call light/bell has been pulled. LPA conducted resident interviews which revealed that some residents do not use their call light/bell and that staff come right away. During LPAs visit the call lights were tested and observed to be operable. The hub had the light indicator on as well as made a buzzing noise, indicating that the call light has been pressed. It was observed that Resident #1 (R1) was not pulling the cord all the way, and then stated that they could not remember where the cord was. LPA asked R1 to pull the cord, however there was no sound emitted. This resulted in staff not being signaled to come to R1's room. It is unknown how often this happens. Each of the residents bedroom have a pull cord next to the ***Continued on 9099-C**.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Javina George
LICENSING EVALUATOR SIGNATURE:

DATE: 06/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 18-AS-20230616115956
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: BUENA VISTA ASSISTED LIVING
FACILITY NUMBER: 331880902
VISIT DATE: 06/20/2023
NARRATIVE
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bed, in the bathroom and in the middle of the room by the recliner chair. In addition rounds are completed every two hours. Per the Administrator it takes staff about three minutes to respond. In the beginning of this month June 2023, the administrator implemented having 3 staff on shift during the NOC shift, it was previously 2, to assist with providing increased care and supervision during resident sleep hours (NOC shift). Based on observation and interviews the allegation of staff do not respond is UNSUBSTANTIATED. A finding of UNSUBSTANTIATED 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 and a copy of this report was provided to Bernadette Best, Administrator.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Javina George
LICENSING EVALUATOR SIGNATURE:

DATE: 06/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 4