336426029-12-7-2022-56-AS-EMAN-CM72P3-20221216163340

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 336426029
Report Date: 12/07/2022
Date Signed: 12/07/2022 11:10:22 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
11/30/2022 and conducted by Evaluator Anna Bueno

PUBLIC

COMPLAINT CONTROL NUMBER: 56-AS-20221130152109

FACILITY NAME:	CALOAKS SENIOR LIVING		FACILITY NUMBER:	336426029
ADMINISTRATOR:	AMELIA ALADIN		FACILITY TYPE:	740
ADDRESS:	3891 POLK STREET		TELEPHONE:	(951) 689-6162
CITY:	RIVERSIDE	STATE: CA	ZIP CODE:	92505
CAPACITY:	74	CENSUS: 51	DATE:	12/07/2022
		UNANNOUNCED	TIME BEGAN:	08:54 AM
MET WITH:	Melissa Bridges		TIME COMPLETED:	11:13 AM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff threw socks at a resident in care.
Staff made inappropriate comments towards resident.
Staff refused to assist resident.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Anna Bueno conducted an unannounced visit to the facility to initiate the investigation of and deliver findings to the above mentioned complaint allegations. LPA identified herself to care manager Melissa Bridges and discussed the purpose of the visit and the elements of the allegations. The investigation included resident and staff interviews and records review.

Allegation 1: Staff threw socks at a resident in care. It was alleged that Staff 1 (S1) threw socks at Resident 1 (R1). Interview with R1 denied that socks were thrown by S1. Witness interview confirm that socks were not thrown at R1 by S1. This complaint is therefore unsubstantiated.

Allegation 2: Staff made inappropriate comments towards resident. R1 alleges that S1 spoke inappropriately to R1 about R1's illness. Witness interviewed deny seeing or hearing this verbal exchange between R1 and S1. Witness further states that it was R1 who would speak inappropriately to S1 and other staff. Resident interviews confirm that they have not been spoken to or heard staff speak inappropriately in this facility. This allegation is

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Anna Bueno	TELEPHONE: 951-204-4307
LICENSING EVALUATOR SIGNATURE:	DATE: 12/07/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/07/2022

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-20221130152109

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: CALOAKS SENIOR LIVING	FACILITY NUMBER: 336426029
	VISIT DATE: 12/07/2022

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

unsubstantiated.

Allegation 3: Staff refused to assist resident. R1 alleges that they were not assisted by S1 during this incident. Witness interview deny that R1 was not assisted and witness further states that S1 was assisting R1 with grooming services during this incident. Interviews with residents reveal that staff assist residents when requested. Staff interview reveal that S1 has not received any accusation similar to this. This allegation is unsubstantiated.

A finding of UNSUBSTANTIATED means 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 with Melissa Bridges and a copy of this report was provided.

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Anna Bueno	TELEPHONE: 951-204-4307
LICENSING EVALUATOR SIGNATURE:	DATE: 12/07/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/07/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 2