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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331881331
Report Date: 06/20/2024
Date Signed: 11/13/2024 01:17:24 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
06/06/2024 and conducted by Evaluator Janira Arreola
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20240606101247
FACILITY NAME:ERICA B INDEPENDENT LIVING FACILITYFACILITY NUMBER:
331881331
ADMINISTRATOR:JOHNSON, LA SUNEAFACILITY TYPE:
735
ADDRESS:3656 GINGER STTELEPHONE:
(818) 818-1817
CITY:PERRISSTATE: CAZIP CODE:
92571
CAPACITY:6CENSUS: 6DATE:
06/20/2024
UNANNOUNCEDTIME BEGAN:
07:45 AM
MET WITH:Licensee, Erica Graham-BullockTIME COMPLETED:
11:45 AM
ALLEGATION(S):
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Staff are not administering medication to residents in care.
Facility violates resident’s personal rights.
INVESTIGATION FINDINGS:
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 The following is an amended report: Licensing Program Analyst (LPA) Janira Arreola, conducted an unannounced visit to the facility to investigate the above allegations. LPA met with Licensee, Erica Graham-Bullock, who was informed of the purpose of the visit. During the visit, LPA conducted interviews, documented observations/conducted a walk through, and conducted records reviews.

It was alleged that “Staff are not administering medication to residents in care.” It was alleged that Client #1 (C1) did not have their medications filled upon admission to the facility causing C1 to miss their evening and following morning dose. LPA conducted client interview which revealed C1 had been admitted to the facility on April 12, 2024 and moved out April 13, 2024. (Report is continued on LIC9099-C Page)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE:

DATE: 06/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2024
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 8
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
06/06/2024 and conducted by Evaluator Janira Arreola
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20240606101247

FACILITY NAME:ERICA B INDEPENDENT LIVING FACILITYFACILITY NUMBER:
331881331
ADMINISTRATOR:JOHNSON, LA SUNEAFACILITY TYPE:
735
ADDRESS:3656 GINGER STTELEPHONE:
(818) 818-1817
CITY:PERRISSTATE: CAZIP CODE:
92571
CAPACITY:6CENSUS: 6DATE:
06/20/2024
UNANNOUNCEDTIME BEGAN:
07:45 AM
MET WITH:Licensee, Erica Graham-BullockTIME COMPLETED:
11:45 AM
ALLEGATION(S):
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2
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9
Licensee does not ensure that residents are sufficiently fed while in care.
Facility smoke detector is in disrepair
INVESTIGATION FINDINGS:
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The following is an amended report: Licensing Program Analyst (LPA) Janira Arreola, conducted an unannounced visit to the facility in order to investigate the above allegations. LPA met with Licensee, Erica Graham-Bullock who was informed of the purpose of the visit. The LPA conducted interviews and records review.

It was alleged that “Licensee does not ensure that residents are sufficiently fed while in care.” It was alleged that lunch was not served by S1. It was also alleged that Client #1 (C1)’s doctor prescribed diet was not accommodated at the facility. LPA conducted staff interview which revealed S1 provides (3) meals a day to clients. Staff interview revealed C1’s medical record was not obtained, however S1 was informed on C1’s diet and provided C1 with a meal of their choosing. (Continued on LIC9099-C Page).
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE:

DATE: 06/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 5 of 8
Control Number 18-AS-20240606101247
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: ERICA B INDEPENDENT LIVING FACILITY
FACILITY NUMBER: 331881331
VISIT DATE: 06/20/2024
NARRATIVE
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(Continued from LIC9099 Page) LPA conducted (14) client interviews. C1 revealed they were not provided with lunch and served foods that did not align with their diet. (13) of (14) client interviews revealed that they receive (3) meals a day. No other clients reported having a doctor ordered diet. LPA conducted records review for (6) current clients and reviewed LIC602 physician’s reports which corroborated no other clients have a doctor ordered diet. Therefore, the preponderance of the evidence standard has not been met.

It was alleged that “Facility smoke detector is in disrepair.” It was alleged that smoke detector outside of C1’s room was chirping at night and later unplugged on April 12,2024. LPA conducted a walk-through of the facility on June 12, 2024 from 2:15pm to 4:15pm and located (2) smoke detectors. (1) was located at the bottom of the stairs and (1) on the second level. During the time of the inspection, staff tested the main detector which made both detectors go off. LPA did not hear chirping during the time of the visit. Client interviews were unable to be conducted as there are currently no clients in care who resided at the facility on April 12, 2024. Therefore, the preponderance of the evidence standard has not been met.

Although the allegations above may have happened or are valid, based on records review, interview, and observation there is no preponderance of evidence to prove the alleged violations did or did not occur. Therefore, the allegation is unsubstantiated. An exit interview was conducted, and a copy of this report was provided.
SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE:

DATE: 06/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2024
LIC9099 (FAS) - (06/04)
Page: 6 of 8
Control Number 18-AS-20240606101247
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: ERICA B INDEPENDENT LIVING FACILITY
FACILITY NUMBER: 331881331
VISIT DATE: 06/20/2024
NARRATIVE
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(Continued from 9099 Page) Client interview revealed that C1 had provided S1 with their medical insurance card to fill their medications on April 12, 2024, but their medication was not filled by S1. LPA conducted staff interview which revealed S1 made attempts to contact C1’s medical provider to fill medications and was informed medications were sent to the wrong pharmacy causing a delay in medications being filled. When C1 moved out on April 13, 2024, C1’s medications were ready to be picked up. Staff interviewed revealed C1 did not come to the facility with medication. Based on staff interview there was no record retained by the facility for C1’s medications as medications were not retained by the facility for C1. In addition, text messages were reviewed dated April 13, 2024 which revealed C1’s medications were ready to be picked up on April 13, 2024. Therefore, the interviews and records review corroborated that C1 did not have their medication until (1) day after admission causing C1 to miss medication doses.

LPA reviewed the records for (6) current clients on June 12, 2024. C2 and C3 had medication initialed as given from June 12 to June 30, 2024 that was whited out. Staff interviewed revealed that a documentation error had prompted the use of the whiteout. Furthermore, both client and staff interviews revealed C4, C5 and C6 had been at the facility for (5) to (6) days but had a medication record started from June 1 to June 12, 2024 where medication was initialed as given for (12) days. Therefore, based on interviews and records review it was found that the preponderance of the evidence standard has been met for medication and documentation errors.

It was alleged that “Facility violates resident’s personal rights”. Several allegations were made pertaining to client personal rights. It was alleged that clients were not permitted to go downstairs after 9pm where the client’s snacks and water was located. It was also alleged that clients were not allowed to have food or drink in their rooms. In addition, it was alleged that S1 had yelled at clients in care.

LPA conducted (14) client interviews. (7) of (14) client interviews revealed snacks are kept in the downstairs area for all clients. (5) of (14) clients revealed they cannot go downstairs before 8am and after 9pm and would “get in trouble” by S1 if they do go downstairs. (2) of (14) clients stated they have access to all parts of the home at any time, while (7) of (14) clients stated they were not sure if this was part of the house rules and do not access the downstairs area late at night or early in the morning. (Report continued on LIC9099-C page).

SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE:

DATE: 06/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 8
Control Number 18-AS-20240606101247
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: ERICA B INDEPENDENT LIVING FACILITY
FACILITY NUMBER: 331881331
VISIT DATE: 06/20/2024
NARRATIVE
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(Continued from LIC9099-C Page) (4) of the (14) clients revealed they did not have access to snacks or water due to house rules not permitting these items in client’s rooms and not having access to downstairs area after 8am and before 9pm where these items are located. (9) of (14) clients stated they have access to snacks in the facility at any time, and staff provide snacks and water. (1) client was unsure of the rules pertaining to snacks and water in the home.

(4) out of (14) clients revealed that S1 yells at clients and threatens to “push out” clients if they do not follow the house rules. (1) of (14) client revealed they do not feel comfortable approaching S1 due to their yelling. (10) of (14) clients revealed S1 and staff are nice to clients and “like” S1.

LPA conducted staff interview who confirmed house rules do not permit clients to have snacks or water in their rooms. Staff interview revealed the house “closes down” at 9pm and clients are to go to their room and not come downstairs after that time except to use the restroom. Staff interviewed revealed this is included in their house rules when they were licensed. Staff interviewed revealed S1 speaks loudly at residents if they are far or cannot hear but denied yelling at clients. Staff interviewed revealed S1 provides reminders for clients to abide by house rules and stated they are not aggressive when speaking with clients.

LPA conducted a file review of the facility’s program plan and house rules submitted to the department. LPA found there are no rules pertaining to food, drink and closing off areas to residents in the program plan. LPA reviewed (6) client files with document title “30 Day Notice” which indicated that if any house rules were broken the client would be removed from the premises “immediately”. Additionally, on June 12, 2024 LPA conducted an unannounced visit and heard S1 yelling at the clients to remove their shoes before entering the home.

Additional allegations were made alleging the facility did not provide comfortable furnishings and basic services to C1. LPA conducted (14) client interviews. C1 revealed they did not have their blankets laundered by S1 and did not have access to clean clothing and blankets. C1 revealed they were not provided with blankets or hand soap in the common restroom. (Continued on LIC9099-C Page)

SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE:

DATE: 06/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 8
Control Number 18-AS-20240606101247
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: ERICA B INDEPENDENT LIVING FACILITY
FACILITY NUMBER: 331881331
VISIT DATE: 06/20/2024
NARRATIVE
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(Continued from LIC9099-C Page) (13) of (14) client interviews revealed that clients having access to their personal belongings, receive laundry services, and have access to clean linens and blankets. (13) of (14) clients interviewed did not recall C1 and services provided to C1. LPA conducted staff interview which revealed that C1 had access to their items at all times, and when C1 moved out they took all their items with them. Staff denied laundry was not done for clients and revealed blankets are provided to clients. LPA conducted inspection on June 12, 2024 and found that all clients had their clothing in their respective closets and found appropriate bedding and linens available at the facility. Additionally, LPA observed the common client restroom had hand soap.

It was also alleged that client’s participation in a day program and church service was mandatory. LPA conducted (7) Client interviews. (1) of (7) client interviews revealed they were informed by S1 that they needed to attend mandatory virtual church services on Sundays, while (6) of (7) client interviews revealed clients do not attend any church services and have not been told by S1 to attend church.

(7) clients interviewed confirmed they learned of a day program service from S1. (1) of (7) client interviews revealed S1 makes attendance mandatory to a day program they did not want to go to. (5) of (7) clients interviewed denied the day program is mandatory and go because they want to, while (1) of (7) client interviews revealed they go to the day program because it is both something they want to do and it is also mandatory by S1. Staff interviewed denied that day program and church services are mandatory for the clients by S1. LPA reviewed the admission agreement for clients in care and did not find any statement requiring clients to attend day program and church services.

Based on LPA’s observations, interviews, and records reviewed, the preponderance of evidence standard has been met. Therefore the above allegation(s) is/are found to be substantiated. California Code of Regulations (Title 22, Division 12, Chapter 1), are being cited on the attached LIC 9099D.

An exit interview was conducted, and a copy of this report was provided.

SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE:

DATE: 06/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2024
LIC9099 (FAS) - (06/04)
Page: 7 of 8
Control Number 18-AS-20240606101247
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: ERICA B INDEPENDENT LIVING FACILITY
FACILITY NUMBER: 331881331
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/20/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/21/2024
Section Cited
CCR
80072(a)
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80072 Personal Rights (a)...each client shall have personal rights which include,but are limited to, the following: This requirment was not met as evidenced by:
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The licensee agreed to meet with the residents and revise the house rules to account for personal rights. The licensee will submit these house rules for approval by the POC due date.
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Based on interview, record review and observation the resident's personal rights in relationship with staff were not respected, as well as access to food and water and parts of the facility related to daily living functions. This poses an immediate personal right health or saftey risk to residents in care.
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Type B
06/27/2024
Section Cited
CCR
80075(b)
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(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. This requirment was not met as evidenced by:
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The licensee agreed to have medication arangements made for clients prior to admission to ensure lapse in medication does not occur. The licensee also agreed to conduct a training with staff on proper medication documentation.
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Based on interview and records review, medications were not filled timely for clients and medication documentation errors occured at the facility. This poses a potential health safety or personal rights risk to residents in care.
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The licensee agreed to document an medication errors and report these to the department in addition to effort made to assist in medication administration. This is due by the POC due date.
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: Tricia Danielson
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE:

DATE: 06/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2024
LIC9099 (FAS) - (06/04)
Page: 8 of 8