331881331-10-13-2025-18-AS-RORN-DMNTP9-20251021145358

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 331881331
Report Date: 10/13/2025
Date Signed: 10/13/2025 12:34:02 PM

Unsubstantiated

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
11/15/2022 and conducted by Evaluator Antonine Richard

COMPLAINT CONTROL NUMBER: 18-AS-20221115101423

FACILITY NAME:	ERICA B INDEPENDENT LIVING FACILITY		FACILITY NUMBER:	331881331
ADMINISTRATOR:	JOHNSON, LA SUNEA		FACILITY TYPE:	735
ADDRESS:	3656 GINGER ST		TELEPHONE:	(818) 818-1817
CITY:	PERRIS	STATE: CA	ZIP CODE:	92571
CAPACITY:	6	CENSUS: 3	DATE:	10/13/2025
		UNANNOUNCED	TIME BEGAN:	08:22 AM
MET WITH:	Erica Bullock		TIME COMPLETED:	01:00 PM

ALLEGATION(S):

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Staff are not dispensing medications as prescribed.

INVESTIGATION FINDINGS:

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On 10/13/2025, Licensing Program Analyst (LPA) Antonine Richard conducted a complaint visit to the facility above and delivered findings on the allegations listed above. LPA met with the Administrator (A1), Erica Bullock, and the purpose of the visit was explained.

The investigation consisted of the following: October 13, 2025, LPA reviewed the records for Client 1 (C1), which included the Admission Agreement dated March 12, 2025, the Physician’s Report dated: March 10, 2025, and the Resident Assessment from March 12, 2025, LPA also obtained the facility's Medication Administration Records log from September 23, 2025 to October 13, 2025, as well as copies of the client and staff rosters dated: 07/01/2025, along with staff training records on Medication Management dated 08/31/2025. LPA obtained emails from the Administrator's communication with the Case Management Mental Health dated November 2022 about the client's medications. LPA conducted interviews with the Administrator (A1), the Nurse (N1), and three clients (C1, C2, and C3).

Report Continued on LIC9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Antonine Richard
LICENSING EVALUATOR NAME: Antonine Richard
LICENSING EVALUATOR SIGNATURE:	DATE: 10/13/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2025

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-20221115101423

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: 10/13/2025

NARRATIVE

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Additionally, LPA Richard reviewed the facility's staff training records for medication management, dated August 20, 2025, which indicated that the staff had received training on how to administer and manage the clients' medications.

Based on LPA Record Reviews and interviews conducted, the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove that the alleged violation occurred. Therefore, the above allegation has been Unsubstantiated.

No deficiencies cited.

An exit interview was conducted. A copy of the report was provided to the Administrator Erica Bullock.

SUPERVISORS NAME: Antonine Richard
LICENSING EVALUATOR NAME: Antonine Richard
LICENSING EVALUATOR SIGNATURE:	DATE: 10/13/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2025

LIC9099 (FAS) - (06/04)

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Control Number 18-AS-20221115101423

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: 10/13/2025

NARRATIVE

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Allegation: Staff are not dispensing medications as prescribed.

The complaint alleged that staff are not administering medications to clients on time, often missing morning doses and attempting to double the afternoon doses. On October 13, 2025, between 8:45 AM and 9:30 AM, the Licensing Program Analyst (LPA) Richard conducted interviews with the Administrator (A1), who denied the allegation. The A1 explained that the facility followed the doctor's prescriptions regarding the timing for administering medications to clients. The nurse at the facility ensures that the medications received from the pharmacy come with clear instructions from the doctor on how they should be administered. A1 uses the Medication Administration Records (MARs) to document all medications that are given. On the same day, the LPA interviewed the nurse (N1), who stated that when the medications arrived from the pharmacy, N1 ensured that the orders matched the clients at the facility. N1 also confirmed that the doctor's orders included instructions on how to administer the medications to the clients.

On October 13, 2025, between 8:45 AM and 9:30 AM, the LPA conducted interviews with three clients (C1, C2, and C3). All three clients reported that they have never experienced any issues with their medications. They also mentioned that the nurse is very helpful with their medication needs. C1 specifically noted that their medications are prescribed to be taken three times a day and that C1 is not missing any doses. On the same date, LPA Richard reviewed the Medication Administration Records (MARs) for each client, covering the period from September 1, 2025, to October 13, 2025, and found no discrepancies.

SUPERVISORS NAME: Antonine Richard
LICENSING EVALUATOR NAME: Antonine Richard
LICENSING EVALUATOR SIGNATURE:	DATE: 10/13/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2025

LIC9099 (FAS) - (06/04)

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