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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331880902
Report Date: 10/23/2023
Date Signed: 10/23/2023 12:08:41 PM

Substantiated


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
07/28/2023 and conducted by Evaluator Javina George
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20230728141755
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: 38DATE:
10/23/2023
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Robin Rebollar-Icamen, AdministratorTIME COMPLETED:
12:20 PM
ALLEGATION(S):
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Staff does not ensure residents records are properly maintained
Resident is left in soiled adult brief for an extended period of time
Staff does not ensure discontinued medications are properly discarded
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Javina George made an unannounced visit to the facility to deliver findings for the allegation(s) listed above. LPA met with Robin Rebollar-Icamen and explained the purpose of the visit and the elements of the allegation(s). The allegation(s) were investigated and the investigation consisted of observations, interviews and a review of both staff and resident records.

Regarding the allegation staff does not ensure residents records are properly maintained.
It was alleged that Staff #1 (S1) had not been charting the resident’s medication logs correctly. As Resident #1 (R1) has a medication that was prescribed that requires to have their vitals taken and documented before the medicine is dispensed. Upon a review of the Medical Administration Record (MAR) revealed that S1 not been had not been taking the R1's vital signs daily or charting the residents’ records for medication dispensed. Additionally, the vitals log, was observed to have been completed or documented R1's vital readings as of July 27, 2023, when it should haved began on July 26, 2023. However upon review of the order, the doctor's order was noted to have been faxed after hours, to the facility at 7:37pm.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Javina George
LICENSING EVALUATOR SIGNATURE:

DATE: 10/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2023
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 6
Control Number 18-AS-20230728141755
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: BUENA VISTA ASSISTED LIVING
FACILITY NUMBER: 331880902
VISIT DATE: 10/23/2023
NARRATIVE
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Upon a further review of R1's facility file, there were not any documents for LPA to review such as Emergency ID Sheet, Admission Agreement, Physician’s Report, Needs/Services, Plan Functional Capabilities, or any Assessment Forms. During today's visit LPA observed for three (3) reviewed files out of (38) resident files to have the required documentation. Based on record review the allegation of staff does not ensure residents records are properly maintained is SUBSTANTIATED.

Resident is left in soiled adult brief for an extended period of time

Per the Business Office Manager/Med Tech Vanessa the incontinent residents are checked every two hours. Interviews conducted with residents revealed that sometimes it is impossible to be checked every two hours but, that when assistance is needed whether calling on the telephone or using their pendant/call button staff responds right away. The Nurse visit notes from an outside agency revealed that R1 had skin irritation believed to have been caused from being left in a soiled brief. Further interviews conducted with facility staff revealed that yes, there are residents that are left in a soiled adult brief and it is usually occurs during shift change, and that staff are reported to ignore the resident call lights. Based on interviews and records review the allegation of resident is left soiled in an adult brief for an extended period of time is SUBSTANTIATED.

Staff does not ensure discontinued medications are properly discarded

During a complaint visit conducted on 08/01/23, LPA conducted a review of R1's medication as well as the Medication Administration Record (MAR) and observed for a medication to have been finished on 7/28/23, however the medication was was still in R1's basket. During today's visit LPA observed for R2 to have medication in their basket that was not on the physician's order. LPA was informed that R2 was admitted to the facility with that medication. R2 was admitted to the facility on 08/04/23. Per Business of Manager/Med Tech Vanessa the medications are disposed of by the facility Nurse, and is done as needed. Per Vanessa the facility Nurse comes to the facility two(2)- three (3) times per week. Based on observations and records review the allegation of staff does not ensure discontinued medications are properly discarded is SUBSTANTIATED. A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

An exit interview was conducted and a copy of this report, and appeal rights were provided to Robin Rebollar-Icamen.
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Javina George
LICENSING EVALUATOR SIGNATURE:

DATE: 10/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 6
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
07/28/2023 and conducted by Evaluator Javina George
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20230728141755

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: 38DATE:
10/23/2023
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Robin Rebollar-Icamen, AdministratorTIME COMPLETED:
12:20 PM
ALLEGATION(S):
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Staff are not providing medications as prescribed to resident(s) in.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Javina George made an unannounced visit to the facility to deliver findings for the allegation(s) listed above. LPA met with Robin Rebollar-Icamen and explained the purpose of the visit and the elements of the allegation(s). The allegation(s) were investigated and the investigation consisted of observations, interviews and a review of both staff and resident records.

Staff are not providing medications as prescribed to resident(s) in care
Per interviews with the Administrator and Business Office Manager/Med Tech the facility's medication cycle begins on the 16th of every month. The Med techs are the only staff allowed to administer and distribute the residents medications. During today's visit LPA observed for each resident to have their own individual basket labled with their name, and all medications were present and accounted for. A review of three (3) resident medications revealed that the medication is being given as prescribed. Based on observation the allegation is UNSUBSTANTIATED. ****Continued on 9099C.

Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Javina George
LICENSING EVALUATOR SIGNATURE:

DATE: 10/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 18-AS-20230728141755
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: BUENA VISTA ASSISTED LIVING
FACILITY NUMBER: 331880902
VISIT DATE: 10/23/2023
NARRATIVE
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A finding that the complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation(s) occurred.

An exit interview was conducted and a copy of this report and appeal rights were provided to Robin Rebollar-Icamen.
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Javina George
LICENSING EVALUATOR SIGNATURE:

DATE: 10/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 18-AS-20230728141755
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: BUENA VISTA ASSISTED LIVING
FACILITY NUMBER: 331880902
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/23/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/06/2023
Section Cited
CCR
87506(a)
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87506 Resident Records (a)The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff. This requirement is
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The licensee agrees to conduct an audit of resident records, and will submit a copy of facility audit checklist. Proof of POC is to be submitted to the department by 5pm on the due date indicated.
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not met as evidenced by: the licensee failed to ensure that 1 out of 1 resident records were maintained with the necessary information for LPA to review. This poses a potential health, safety and personal rights risk to persons in care.
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Type B
11/06/2023
Section Cited
CCR
87468.2(a)(4)
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87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a) ... Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (4) To care, supervision, and services that
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The licensee agrees to increase staffing on the NOC shift, by adding an additional staff.
Proof of POC is to be submitted to the department by 5pm on the due date indicated.
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meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement is not met as evidenced by: the licensee failed to ensure that residents were checked and chanaged as required.
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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: Jazmond D Harris
LICENSING EVALUATOR NAME: Javina George
LICENSING EVALUATOR SIGNATURE:

DATE: 10/23/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 18-AS-20230728141755
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: BUENA VISTA ASSISTED LIVING
FACILITY NUMBER: 331880902
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/23/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/23/2023
Section Cited
CCR
87465(i)(3)
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87465 Incidental Medical and Dental Care Prescription medications which are not taken with the resident upon termination of services, not returned to the issuing pharmacy, nor retained in the facility as ordered by the resident’s physician and documented
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The requirement is not met as evidenced by: the licensee failed to destroy a discontinued medication 1 out of 1 times. This poses a potential heath, and safety risk to persons in care.
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in the resident’s established record procedures or which are otherwise to be disposed of shall be destroyed in the facility by the facility administrator and one other adult who is not a resident. Both shall sign a record, to be retained for at least three years, which lists the following:
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The licensee agrees to conduct an audit of medications and physician orders, and destroy and needed medication. Proof of POC is to be submitted to the department by 5pm on the due date indicated.
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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: Jazmond D Harris
LICENSING EVALUATOR NAME: Javina George
LICENSING EVALUATOR SIGNATURE:

DATE: 10/23/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2023
LIC9099 (FAS) - (06/04)
Page: 6 of 6