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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 336402596
Report Date: 05/09/2023
Date Signed: 05/09/2023 03:19:37 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
06/13/2022 and conducted by Evaluator Jesse Gardner
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20220613122908
FACILITY NAME:SLB INCORPORATED-BAMBIFACILITY NUMBER:
336402596
ADMINISTRATOR:FORTAJADA, JAMIELAHFACILITY TYPE:
735
ADDRESS:13331 BAMBI COURTTELEPHONE:
(951) 653-0604
CITY:MORENO VALLEYSTATE: CAZIP CODE:
92553
CAPACITY:6CENSUS: 6DATE:
05/09/2023
UNANNOUNCEDTIME BEGAN:
02:36 PM
MET WITH:Noel Castillo, CaregiverTIME COMPLETED:
03:35 PM
ALLEGATION(S):
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Resident sustained multiple fractures while in care
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPAs) Jesse Gardner and Janette Romero arrived unannounced to deliver findings to an investigation into the allegation listed above. LPAs met with Caregiver Noel Castillo and toured the facility. CEO Michael Hall and Administrator Jamielah Fortejada arrived while inside the facility.

The Department investigated this complaint and found that Resident 1 (R1) was transported to Riverside University Health System (RUHS) by ambulance on June 3, 2022, due to being lethargic, a persistent cough and labored breathing. While admitted to RUHS, the facility was notified that R1 had rib fractures and compression fractures of R1’s vertebra as well as an old fracture of R1’s left clavicle. Upon interviews with staff, all appeared to be in shock that R1 had fractures and denied R1 had fallen while in their care.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Jesse Gardner
LICENSING EVALUATOR SIGNATURE:

DATE: 05/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2023
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 2
Control Number 18-AS-20220613122908
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: SLB INCORPORATED-BAMBI
FACILITY NUMBER: 336402596
VISIT DATE: 05/09/2023
NARRATIVE
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All residents in the facility are non-verbal and were therefore, not able to be interviewed. Medical records provided by the facility from RUHS indicate that the fractures R1 sustained are due to compression. During visits made by the Department, R1 was observed sitting in their wheelchair and was seen to be compressed to one side. Medical records reviewed indicated that R1’s diagnosis of compression deformity was likely secondary to R1’s condition, osteoporosis. Thus, there was insufficient evidence to corroborate that R1 sustained fractures while in care at SLB Incorporated due to neglect/lack of supervision.

Thus, the Department found this allegation to be UNSUBSTANTIATED. A finding of UNSUBSTANTIATED means that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur.

An exit interview was conducted where a copy of this report was discussed with and provided to CEO Michael Hall.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Jesse Gardner
LICENSING EVALUATOR SIGNATURE:

DATE: 05/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2