331881273-11-7-2023-18-AS-RSTS-CXYSGQ-20231127125218

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 331881273
Report Date: 11/07/2023
Date Signed: 11/07/2023 03:11:35 PM

Unfounded

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
11/03/2023 and conducted by Evaluator Stephanie Martinez

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20231103101819

FACILITY NAME:	AVERY GARDEN SENIOR CARE HOME, INC.		FACILITY NUMBER:	331881273
ADMINISTRATOR:	THOMAS, LINDA		FACILITY TYPE:	740
ADDRESS:	26600 IRONWOOD AVE.		TELEPHONE:	(818) 515-9279
CITY:	MORENO VALLEY	STATE: CA	ZIP CODE:	92555
CAPACITY:	8	CENSUS: 8	DATE:	11/07/2023
		UNANNOUNCED	TIME BEGAN:	08:40 AM
MET WITH:	Linda Thomas, Administrator		TIME COMPLETED:	03:15 PM

ALLEGATION(S):

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Facility staff are not assisting resident with medical appointments.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA), Stephanie Martinez, conducted an unannounced visit to the facility to start the investigation into the above allegations. The LPA met with Administrator, Linda Thomas, and informed her of the purpose of the visit.

The Department received a report alleging facility staff are not assisting Resident One (R1) with obtaining further medical testing or with dental appointments. The LPA conducted staff/resident interviews, reviewed records, and obtained copies of relevant documentation.Staff interviews revealed the Licensee, Linda Thomas, and staff member, Erik Thomas, have been assisting R1 with medical appointments. It was reported R1 changes their mind from wanting staff assistance with scheduling medical and dental appointments to wanting to schedule the appointments on their own. Resident interviews report facility staff provide assistance with medical appointments by calling for appointments, providing transportation, and providing supervision during appointments. In addition, resident daily notes revealed R1, on 11/04/2023, was visited by a medical

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Rikesha Stamps	TELEPHONE: (951) -212-0616
LICENSING EVALUATOR NAME: Stephanie Martinez	TELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:	DATE: 11/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 18-AS-20231103101819

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: AVERY GARDEN SENIOR CARE HOME, INC.	FACILITY NUMBER: 331881273
	VISIT DATE: 11/07/2023

NARRATIVE

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professional at the facility, though, refused to meet with and began to yell at the individual. Text messages from R1 to staff revealed R1 cancelled their own dental appointment on 10/30/2023. Finally, when R1 was interviewed it was reported the resident did have dental appointments scheduled, however, they could not show up for a variety of reasons. Therefore, based on interviews and records, this allegation is deemed UNFOUNDED. A finding that the complaint is unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis.

An exit interview was conducted with Administrator Thomas; this report was reviewed and a copy was provide.

SUPERVISOR'S NAME: Rikesha Stamps	TELEPHONE: (951) -212-0616
LICENSING EVALUATOR NAME: Stephanie Martinez	TELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:	DATE: 11/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 3

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
11/03/2023 and conducted by Evaluator Stephanie Martinez

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20231103101819

FACILITY NAME:	AVERY GARDEN SENIOR CARE HOME, INC.		FACILITY NUMBER:	331881273
ADMINISTRATOR:	THOMAS, LINDA		FACILITY TYPE:	740
ADDRESS:	26600 IRONWOOD AVE.		TELEPHONE:	(818) 515-9279
CITY:	MORENO VALLEY	STATE: CA	ZIP CODE:	92555
CAPACITY:	8	CENSUS: 8	DATE:	11/07/2023
		UNANNOUNCED	TIME BEGAN:	08:40 AM
MET WITH:	Linda Thomas, Administrator		TIME COMPLETED:	03:15 PM

ALLEGATION(S):

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Facility staff are not providing quality food for resident.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA), Stephanie Martinez, conducted an unannounced visit to the facility to start the investigation into the above allegations. The LPA met with Administrator, Linda Thomas, and informed her of the purpose of the visit. The Department also received a report alleging facility staff are not providing R1 with nutritious meals. The investigation included staff/resident interviews, reviewed records, and obtained copies of relevant documentation. The LPA conducted staff/resident interviews, reviewed records, and obtained copies of relevant documentation. Staff and resident interviews revealed the home provides residents with nutritious and healthy meals. The LPA observed the facility's food supply and observed proteins, vegetables and fruits available. In addition, the LPA observed R1's private food supply to include proteins, vegetables and fruits available. Staff interviews revealed R1 cooks for themself and will occasionally ask staff to prepare their meals. Therefore, based on interviews, this allegation is deemed UNSUBSTANTIATED at this time. 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 occurred. An exit interview was conducted with Administrator Thomas; this report was reviewed with her and a copy was provide.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Rikesha Stamps	TELEPHONE: (951) -212-0616
LICENSING EVALUATOR NAME: Stephanie Martinez	TELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:	DATE: 11/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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