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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 335530134
Report Date: 05/19/2026
Date Signed: 05/19/2026 01:10:45 PM

Substantiated


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
10/08/2025 and conducted by Evaluator Beena Singh
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20251008213046
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: 85DATE:
05/19/2026
UNANNOUNCEDTIME BEGAN:
10:40 AM
MET WITH:Wellness Director Victoria OngTIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Staff did not seek medical attention to resident resulting in hospitalization.
INVESTIGATION FINDINGS:
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First Allegation: Staff did not seek medical attention to resident resulting in R#1’s hospitalization.

Licensing Program Analyst (LPA) Beena Singh conducted an unannounced visit to the facility to deliver findings on a complaint alleging Staff did not seek medical attention to resident resulting in R#1’s hospitalization. LPA Singh met with Wellness Director Victoria Ong, facility representative. The investigation conducted by Department staff consisted of interviews and reviews of pertinent records.

Department Staff substantiated the allegation of neglect and lack of care and supervision regarding Resident #1, concluding that staff failed to seek timely medical attention, which ultimately led to the residents’ hospitalization. During an interview, the family of Resident #1 reported observing significant signs of physical and cognitive decline during a visit on September 29, 2025, two days before the resident was transferred to the hospital.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Beena Singh
LICENSING EVALUATOR SIGNATURE:

DATE: 05/19/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2026
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-20251008213046
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: 05/19/2026
NARRATIVE
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These symptoms included pronounced lethargy, incoherent speech, an inability to complete a routine walk, and a noticeable decrease in appetite, all of which went unaddressed by facility personnel at the time.
Facility staff reported to department Staff that they did not observe a change in Resident #1’s condition until October 1, 2025, when the resident failed to get out of bed. Although the facility notified the family that day, it was the family who, upon arrival and observation of the resident’s decline, insisted on an immediate hospital transfer. Resident #1 was subsequently admitted to Park view Community Hospital suffering from a blood sugar level in the 600s, diabetic ketoacidosis, and hyperglycemia. The clinical evaluation further revealed hemodynamic instability, altered mental status, dehydration, and severe electrolyte imbalances, including hypokalemia, hyperkalemia, and hypernatremia. Staff indicated that R1’s diabetes was controlled by diabetic medication. However, there was no documentation or formal orders showing why the medication was discontinued on July 13, 2025.

Based on the evidence the allegation that Staff did not seek medical attention to resident#1 resulting in hospitalization due to neglect/lack of care and supervision is Substantiated. A substantiated finding means that the allegation is valid because the preponderance of the evidence standard has been met.
California Code of Regulations (Title 22, Division & Chapter number) are being cited on the attached LIC 9099D). An Immediate civil penalty for a violation has been assessed in the amount of $500.00.


An exit interview was conducted where reports (LIC9099, LIC9099-C & LIC9099-D) LIC 421BG (6/17) and Appeal Rights were discussed and provided to Wellness Director Victoria Ong, Facility representative at the conclusion of the visit.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Beena Singh
LICENSING EVALUATOR SIGNATURE:

DATE: 05/19/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2026
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
10/08/2025 and conducted by Evaluator Beena Singh
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20251008213046

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: 85DATE:
05/19/2026
UNANNOUNCEDTIME BEGAN:
10:40 AM
MET WITH:Wellness Director Victoria OngTIME COMPLETED:
02:00 PM
ALLEGATION(S):
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9
Staff did not ensure resident was hydrated.
Staff did not ensure resident was fed.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Beena Singh conducted an unannounced visit to the facility to deliver findings on a complaint alleging neglect/Lack of care. LPA Singh met with Administrator Griselda T. Garcia, facility representative. The investigation conducted by Department staff consisted of interviews and reviews of pertinent records.

Second Allegation:-Staff did not ensure resident was hydrated.
Department Staff did the investigation and investigation did not provide sufficient evidence to substantiate the allegation that staff did not ensure that the resident#1 was hydrated. Resident#1 was admitted to Parkview Community Hospital due to diabetic ketoacidosis and dehydration. During when department staff interviewed the facility staff stated they provided water to the resident while at the facility.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Beena Singh
LICENSING EVALUATOR SIGNATURE:

DATE: 05/19/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2026
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-20251008213046
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: 05/19/2026
NARRATIVE
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Third Allegation:- Staff did not ensure resident was fed.

During the investigation department Staff interviewed Staff, the facility staff stated they provided food to the resident while at the facility. The facility staff also observed Resident#1 with a decrease in

appetite the last two days prior to him being sent out to the hospital, was caused due to ketoacidosis

and state of his health at that time. According to Staff R#1 normally had a very good appetite and when R#1 had a decrease in appetite, it alerted the staff to the change in condition.

Staff did not ensure that the resident was hydrated and Staff did not ensure resident was fed are

Unsubstantiated due to the possibility that the dehydration and decrease in appetite was caused due to ketoacidosis and state of his health at that time.

Based on the evidence found during the investigation, the allegations listed above are deemed


UNSUBSTANTIATED. A finding that the complaints are UNSUBSTANTIATED means although the
allegation may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. During today’s visit, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations.

An exit interview was conducted where reports (LIC9099, LIC9099-C were discussed and provided to Well-ness Director Victoria Ong, Facility representative at the conclusion of the visit.

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

DATE: 05/19/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2026
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 56-AS-20251008213046
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: 05/19/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/20/2026
Section Cited
CCR
87466
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Observation of the Resident..The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning...When changes such as unusual weight gains or losses or deterioration of mental ability or a physical health condition are observed, documented.. brought to the attention of the resident's physician and the resident's responsible person...This requirement is not met as evidenced by:
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Licensee to train all staff on CCR 87466 and submit proof of Training Log to LPA Beena Singh by POC due date. Licensee stated to submit signed Statement of Understanding on CCR 874666 and submit to LPA Singh by POC due date.
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Based on the evidence, the Licensee/Staff failed to provide timely medical attention, resulting in hospitalization of Resident#1, which pose immediate health, safety, and personal rights risk to residents in care.
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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: 05/19/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2026
LIC9099 (FAS) - (06/04)
Page: 5 of 5