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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 336412332
Report Date: 08/11/2023
Date Signed: 08/11/2023 02:09:17 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
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, CA
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/17/2020 and conducted by Evaluator Paola Guerrero
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20201217094817
FACILITY NAME:NATHANS ADULT RESIDENTIAL CARE HOMEFACILITY NUMBER:
336412332
ADMINISTRATOR:JED AQUINOFACILITY TYPE:
735
ADDRESS:10980 KAYJAY ST.TELEPHONE:
(951) 353-2199
CITY:RIVERSIDESTATE: CAZIP CODE:
92503
CAPACITY:6CENSUS: 4DATE:
08/11/2023
UNANNOUNCEDTIME BEGAN:
01:55 PM
MET WITH: Myrna EvengelistaTIME COMPLETED:
02:15 PM
ALLEGATION(S):
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Facility failed to provide transportation for resident to receive medical care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Paola Guerrero conducted an unannounced visit to deliver findings on the allegation listed above. LPA met with Facility Caregiver Myrna Evengelista and explained the purpose of the visit. The investigation consisted of interviews and review of records.

Regarding the first allegation facility failed to provide transportation for resident to receive medical care. After further investigation it was discovered that facility failed to provide transportation for resident to receive medical care. Facility instead transported Resident #1 (R1) to conservator’s home where conservator transported Resident #1 (R1) to ER on 12/3/2020 to receive medical care. Based on facilities admission agreement facility failed to provide transportation for resident to receive medical care as stated. Based on the evidence gathered during the investigation, the above allegation is Substantiated.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Paola Guerrero
LICENSING EVALUATOR SIGNATURE:

DATE: 08/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2023
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 3
Control Number 18-AS-20201217094817
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
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, CA

FACILITY NAME: NATHANS ADULT RESIDENTIAL CARE HOME
FACILITY NUMBER: 336412332
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/11/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/18/2023
Section Cited
CCR
80075(a)
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Health Related Services (a) The licensee shall ensure that each client receives necessary first aid and other needed medical or dental services, including arrangement for and/or provision of transportation to the nearest available services...
This requirement is not met as evidence by:
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Administrator/and Lincensee will read the entire Health Related Services regulation will train staff on the above regulation and will provide acknowledgement of undertanding singed by all staff. Acknowledgement will be sent via email to responsible LPA by 8/18/2023.
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Based on observations, interviews and record review, the licensee did not ensure Health related services to be obtained. Which poses an immediate Health, Safety, or Personal Rights risk to persons 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: Paola Guerrero
LICENSING EVALUATOR SIGNATURE:

DATE: 08/11/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 18-AS-20201217094817
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA
FACILITY NAME: NATHANS ADULT RESIDENTIAL CARE HOME
FACILITY NUMBER: 336412332
VISIT DATE: 08/11/2023
NARRATIVE
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A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Title 22 regulations Health Related Services 80075(a) from division 6, chapter, article 6, is being cited on the attached LIC 9099 D.

An exit interview was conducted where this report was discussed, and appeal rights were provided to Facility Administrator Myrna Evengelista.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Paola Guerrero
LICENSING EVALUATOR SIGNATURE:

DATE: 08/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3