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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 336425840
Report Date: 04/29/2025
Date Signed: 04/29/2025 11:53:26 AM

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
04/28/2025 and conducted by Evaluator Javier Prieto
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20250428092422
FACILITY NAME:RIVERSIDE MEMORY CAREFACILITY NUMBER:
336425840
ADMINISTRATOR:TAWFIK, EVAFACILITY TYPE:
740
ADDRESS:6280 CLAY STREETTELEPHONE:
(951) 360-1616
CITY:RIVERSIDESTATE: CAZIP CODE:
92509
CAPACITY:110CENSUS: 78DATE:
04/29/2025
UNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Eva Tawfik, Executive DirectorTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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9
Staff did not follow resident's hospice care plan
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 - Interview with Memory Care Director (S1) states that facility medical tech staff were following the care plan for dispensing pain medication to resident #1 (R1). Medication orders were obtained during today's investigation which indicates that R1 is to receive pain medication as needed at the duration of every four (4) hours, as needed. The order reads that the form of dispensing this medication are a crushed pill, in 1 ml of liquid, and dispensed in a syringe for oral dispensing. The facility as a crush order from the hospice agency for dispensing in this manner. S1 states that med tech staff were following procedures by dispensing of pain medication per written order and are not allowed to dispense this medication with a verbal order. S1 states that med tech staff were following protocol by not accepting a verbal order and only following orders that were in writing. A copy of R1's Medication Administration Record (MAR) log was obtained at time of investigation.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Javier Prieto
LICENSING EVALUATOR SIGNATURE:

DATE: 04/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2025
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 2
Control Number 56-AS-20250428092422
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: 04/29/2025
NARRATIVE
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Based on the information obtained there is not enough evidence that staff did not follow resident's hospice care plan. Therefore, the allegations are deemed UNSUBSTANTIATED at this time. This report was signed by LPA Prieto and Memory Care Director Annette Buenrostro and a copy was left with the facility.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Javier Prieto
LICENSING EVALUATOR SIGNATURE:

DATE: 04/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2