336425840-3-13-2025-56-AS-KCLS-DLZPRG-20250930113240

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 336425840
Report Date: 03/13/2025
Date Signed: 03/13/2025 02:43:44 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/07/2025 and conducted by Evaluator Javier Prieto

COMPLAINT CONTROL NUMBER: 56-AS-20250307103003

FACILITY NAME:	RIVERSIDE MEMORY CARE		FACILITY NUMBER:	336425840
ADMINISTRATOR:	TAWFIK, EVA		FACILITY TYPE:	740
ADDRESS:	6280 CLAY STREET		TELEPHONE:	(951) 360-1616
CITY:	RIVERSIDE	STATE: CA	ZIP CODE:	92509
CAPACITY:	110	CENSUS: 72	DATE:	03/13/2025
		UNANNOUNCED	TIME BEGAN:	12:30 PM
MET WITH:	Eva Tawfik, Executive Director		TIME COMPLETED:	02:50 PM

ALLEGATION(S):

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Staffs are not assisting resident with self administered medications.

Staffs not reporting incidents to resident representative

Medications given to a resident without primary physician authorization.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Javier Prieto visited the facility to investigate a complaint. LPA Prieto met with Executive Director Tawfik and discussed the details of the complaint.

Allegation #1
LPA Prieto addressed the matter of medications being dispensed to Resident #1 (R1) with the Memory Care Director (S1). S1 confirmed that R1’s medication was dispensed as prescribed. During the investigation, S1 provided LPA Prieto with a copy of R1’s Medication Administration Record (MAR) log, which showed that medications were given as prescribed.

Allegation #2
Interviews with S1 and Executive Director (S2) revealed that communication was conducted with R1's responsible parties. Proof of this communication was obtained during the investigation. Additionally, S1 provided LPA Prieto with resident Narrative Charting regarding R1’s medication, care, and notifications to the responsible parties.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Javier Prieto
LICENSING EVALUATOR SIGNATURE:	DATE: 03/13/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/13/2025

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 56-AS-20250307103003

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: RIVERSIDE MEMORY CARE	FACILITY NUMBER: 336425840
	VISIT DATE: 03/13/2025

NARRATIVE

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Allegation #3

The MAR log for R1, provided by S1, showed that medications were administered as prescribed by a physician. Orders related to changes or discontinuation of R1’s medication were also documented in the MAR log. Narrative Charting concerning R1’s medication, care, and notifications to responsible parties confirmed communication regarding changes in medications as prescribed by the physician.

Based on the information obtained, there is insufficient evidence to substantiate the allegations that staff are not assisting residents with self administered medications, not reporting incidents to resident representatives, or administering medications without primary physician authorization. Therefore, these allegations are deemed UNSUBSTANTIATED at this time.

This report was signed by LPA Prieto and Executive Director Tawfik, and a copy was left with the facility.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Javier Prieto
LICENSING EVALUATOR SIGNATURE:	DATE: 03/13/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/13/2025

LIC9099 (FAS) - (06/04)

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