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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 335530134
Report Date: 08/12/2025
Date Signed: 08/12/2025 12:48:28 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO 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
03/25/2025 and conducted by Evaluator Beena Singh
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20250325093823
FACILITY NAME:GARDENS OF RIVERSIDE, THEFACILITY NUMBER:
335530134
ADMINISTRATOR:GARCIA, GRISELDA "GRACIE".FACILITY TYPE:
740
ADDRESS:10849 ARLINGTON AVENUETELEPHONE:
(951) 637-8844
CITY:RIVERSIDESTATE: CAZIP CODE:
92505
CAPACITY:98CENSUS: 88DATE:
08/12/2025
UNANNOUNCEDTIME BEGAN:
11:50 AM
MET WITH:Facility Executive Director Griselda Gracie GarciaTIME COMPLETED:
01:00 PM
ALLEGATION(S):
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 Staff hit a resident while in care.
Staff threatened a resident while in care.
INVESTIGATION FINDINGS:
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On 8/12/2025 at 11:50 AM, Licensing Program Analysts (LPA) Beena Singh conducted an unannounced visit to the facility to deliver findings on a complaint alleging neglect/lack of supervision. LPA Singh met with Facility Executive Director Griselda Gracie Garcia, facility representative, and was granted entry into the facility. The investigation conducted by Department staff consisted of interviews and reviews of pertinent records.

First Allegation: Staff hit a resident while in care.
The allegation of Physical abuse against resident#1 (R1) is found to be Unsubstantiated. While the resident made verbal statements alleging that R1 was “hit” by a caregiver, there were no direct witnesses to the alleged physical abuse. Records show that R1 has cognitive impairment and dementia, making R1 unable to consistently recall or provide accurate information about the incident. In addition, caregivers reported that R1 has a history of confusion and making inconsistent statements.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Beena Singh
LICENSING EVALUATOR SIGNATURE:

DATE: 08/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2025
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 5
Control Number 56-AS-20250325093823
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: GARDENS OF RIVERSIDE, THE
FACILITY NUMBER: 335530134
VISIT DATE: 08/12/2025
NARRATIVE
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There was no direct observation, forensic evidence (like a medical report of an injury consistent with abuse), or other witness statements to support the claim that the injury was intentionally caused. Therefore, based on the evidence gathered during the investigation, the allegations listed above is deemed UNSUBSTANTIATED. A finding that the complaints are UNSUBSTANTIATED means although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur.

Third Allegation: Staff threatened a resident while in care.

The allegation of staff threatened resident 1 (R1) is found to be Unsubstantiated. While the resident made verbal statements alleging that R1 was “threatened” by a caregiver, there were no direct witnesses to the alleged staff threatening R1. Due to the victim’s diagnosis R1 was unable to recall the incident or provide accurate information in a consistent manner.

Based on the evidence, there is insufficient evidence to prove that staff willingly threatened R1. Therefore, the finding is found to be unsubstantiated, it means there isn't enough evidence to confirm that the allegation occurred.

Based on the evidence gathered during the investigation, the allegations listed above are deemed UNSUBSTANTIATED. A finding that the complaints are UNSUBSTANTIATED means although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur.

An exit interview was conducted where this report (LIC9099), LIC 9099C was discussed and provided to Facility Executive Director Griselda 'Gracie' Garcia.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Beena Singh
LICENSING EVALUATOR SIGNATURE:

DATE: 08/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO 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
03/25/2025 and conducted by Evaluator Beena Singh
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20250325093823

FACILITY NAME:GARDENS OF RIVERSIDE, THEFACILITY NUMBER:
335530134
ADMINISTRATOR:GARCIA, GRISELDA "GRACIE".FACILITY TYPE:
740
ADDRESS:10849 ARLINGTON AVENUETELEPHONE:
(951) 637-8844
CITY:RIVERSIDESTATE: CAZIP CODE:
92505
CAPACITY:98CENSUS: 88DATE:
08/12/2025
UNANNOUNCEDTIME BEGAN:
11:50 AM
MET WITH:Facility Executive Director Griselda Gracie GarciaTIME COMPLETED:
01:00 PM
ALLEGATION(S):
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2
3
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9
Staff caused injuries to a resident while in care.
INVESTIGATION FINDINGS:
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 On 8/12/2025 at 11:50 AM, Licensing Program Analysts (LPA) Beena Singh conducted an unannounced visit to the facility to deliver findings on a complaint alleging neglect/lack of supervision. LPA Singh met with Facility Executive Director Griselda Gracie Garcia, facility representative, and was granted entry into the facility. The investigation conducted by Department staff consisted of interviews and reviews of pertinent records.
Second Allegation- R1 fell and sustained multiple injuries due to staff neglect.

On March 5, 2025, R1 was transported to the hospital due to a head injury resulting from an unwitnessed mechanical fall from bed. Notes state R1 was found on the ground next to her bed with a contusion to her right forehead and left forearm. R1’s primary complaint was neck pain. R1 was diagnosed with a minimally displaced left nasal bone fracture and a right frontal scalp hematoma.
Resident#1, who is assessed as a total assist and requires a Hoyer lift for all transfers, sustained injuries during a fall.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Beena Singh
LICENSING EVALUATOR SIGNATURE:

DATE: 08/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2025
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 5
Control Number 56-AS-20250325093823
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: GARDENS OF RIVERSIDE, THE
FACILITY NUMBER: 335530134
VISIT DATE: 08/12/2025
NARRATIVE
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This incident occurred while the resident was being assisted by a staff member without the required Hoyer lift or the assistance of a second staff person, directly violating the resident's documented care plan. This failure to follow established protocols resulted in a preventable injury to R1.

Based on observations, interviews, record reviews, and the totality of evidence gathered, there is sufficient evidence to support the allegation. The preponderance of evidence standard has been met, leading to the substantiated finding of Neglect/Lack of Care & Supervision.

An exit interview was conducted, and this report (LIC809) LIC 809C, LIC809D and Appeal Rights were discussed and provided to Facility Executive Director Griselda Gracie Garcia.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Beena Singh
LICENSING EVALUATOR SIGNATURE:

DATE: 08/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 56-AS-20250325093823
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: GARDENS OF RIVERSIDE, THE
FACILITY NUMBER: 335530134
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/12/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/13/2025
Section Cited
CCR
87411(a)
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CCR 87411 Personnel Requirements – General-(a) Facility personnel shall at all times be sufficient in numbers.. In facilities licensed for sixteen or more.. to ensure provision of personal assistance and care as required in Section 87608, Postural Supports..The licensing agency may require any facility to ..provide...additional staff for the provision of adequate services.
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Licensee/ facility administrator agrees, will submit proof of training to LPA Beena Singh by the plan of correction (POC) due date on 8/13/2025.
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Based on evidence, the licensee did not ensure sufficient staff to prevent R1 from falling and sustaining multiple injuries, which poses a potential Health, Safety, or Personal Rights risk to persons in care.
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Plan of Correction: - POC due date-8/13/2025
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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: Efren Malagon
LICENSING EVALUATOR NAME: Beena Singh
LICENSING EVALUATOR SIGNATURE:

DATE: 08/12/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5