336426029-4-13-2023-56-AS-EMAN-CRBPKC-20230428112253

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 336426029
Report Date: 04/13/2023
Date Signed: 04/13/2023 03:39:42 PM

Substantiated

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
04/10/2023 and conducted by Evaluator Melody Brown

PUBLIC

COMPLAINT CONTROL NUMBER: 56-AS-20230410111201

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: 56	DATE:	04/13/2023
		UNANNOUNCED	TIME BEGAN:	12:00 PM
MET WITH:	Licensee/Administrator Amelia Aladin		TIME COMPLETED:	03:55 PM

ALLEGATION(S):

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Staffs are not providing a diabetic diet for resident

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Melody Brown conducted an unannounced visit to the facility 04/13/2023 at 12:00 PM to initiate a complaint investigation. LPA Brown was greeted and granted entrance to the facility by a staff and Licensee/Administrator Amelia Aladin met with LPA Brown. LPA Brown explained the purpose of the visit.

The investigation was conducted by LPA Melody Brown. The investigation consisted of observations, records review and interviews with relevant parties. The allegation indicates that Staffs are not providing a diabetic diet for residents. LPA Brown obtained evidence to corroborate the allegation. Interviews with residents indicated they were not informed of diabetic menu available and that they eat what’s available for them, they eat what the staffs served which are the same food as the other residents. Residents interview revealed that each meal, they were either served with fruit punch, lemonade and orange juice that are all high on sugar. Residents’ interviews indicated that snacks provided were all high of sugar like fruit juices and cookies, no diabetic snacks available for residents with diabetes. ***Continuation in LIC9099C ***

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody Brown	TELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:	DATE: 04/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/13/2023

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 5

Control Number 56-AS-20230410111201

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: 04/13/2023

NARRATIVE

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Staffs’ interviews indicated that they don’t have diabetic menu for the residents’, but they are serving small portions of food to diabetic residents. Staffs’ interviews revealed that diabetic residents were served the same food as the other residents. Kitchen staffs reported to LPA Brown that they are serving the regular fruit juices like fruit punch, lemonade and orange juice to diabetic residents as they do not have sugar free drinks to serve diabetic residents with their meals. Kitchen staffs added that if they are serving pancakes to residents with diabetes, they are serving it with the regular pancake syrup as they do not have the sugar free syrup for the residents with diabetes. Staffs interviews revealed that cookies and fruit juices served to residents for snacks are not sugar free. LPA Brown observed during records review that the facility menu does not have diabetic choices for residents with diabetes. Also, during the visit, LPA Brown toured the facility kitchen and observed the pie, pudding, ice cream, cake or jello listed in their menu don't have sugar free items/choices for diabetic residents. LPA Brown also noted that only regular orange juice, lemonade and fruit punch are available in the kitchen and no sugar free drinks available for residents with diabetes to serve each meal. LPA Brown observed Sweet Plus, a zero calorie sweetener in the kitchen that staff reported that they are giving to diabetic residents when they are serving coffee in the morning for diabetic residents that wants coffee. LPA Brown informed Licensee/Administrator Aladin that deficiency will be cited as this pose potential risks to residents in care.

Based on LPA Brown’s observations and records review, the preponderance of evidence standard has been met, and therefore the above allegation of Staffs are not providing a diabetic diet for residents found to be SUBSTANTIATED. A finding that the complaint is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met. California Code of Regulations, (Title 22, Division 6 & Chapter 8) is cited on the attached LIC9099D.

An exit interview was conducted where this report (LIC9099), LIC9099D and Appeal Rights were discussed and provided to Licensee/Administrator Amelia Aladin.

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody Brown	TELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:	DATE: 04/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/13/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 5

Control Number 56-AS-20230410111201

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/13/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 04/24/2023 Section Cited CCR 87628(b)(4)	1 2 3 4 5 6 7	87628 Diabetes (b) In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensee shall be responsible for the following: (4) Providing modified diets as prescribed by a resident's physician as specified... This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Licensee stated to submit updated facility menu that includes diabetic diet for residents with diabetes and submit to LPA Brown by POC due date. Licensee stated to submit signed Statement of Understanding on CCR 87628(b)(4) to LPA Brown by POC due date.
	8 9 10 11 12 13 14	Based on interview and records review, the Licensee did not comply with the section cited above by not providing diabetic diet for residents diagnosed with diabetes which pose potential health, safety and personal rights rights risks to residents in care.	8 9 10 11 12 13 14
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	1 2 3 4 5 6 7		1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody Brown	TELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:	DATE: 04/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/13/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 5

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
04/10/2023 and conducted by Evaluator Melody Brown

PUBLIC

COMPLAINT CONTROL NUMBER: 56-AS-20230410111201

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: 56	DATE:	04/13/2023
		UNANNOUNCED	TIME BEGAN:	12:00 PM
MET WITH:	Licensee/Administrator Amelia Aladin		TIME COMPLETED:	03:55 PM

ALLEGATION(S):

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Food is not of nutritious value to meet the needs of residents

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Melody Brown conducted an unannounced visit to the facility 04/13/2023 at 12:00 PM to initiate a complaint investigation. LPA Brown was greeted and granted entrance to the facility by a staff and Licensee/Administrator Amelia Aladin met with LPA Brown. LPA Brown explained the purpose of the visit.

The investigation was conducted by LPA Melody Brown. The investigation consisted of observations, records review and interviews with relevant parties. The allegation indicates that Food is not of nutritious value to meet the needs of residents. During the investigation, LPA Brown did not find evidence to corroborate the allegation. Interviews with residents and staffs indicated that the facility's serving nutritious food to the residents. Residents and staffs interviews revealed no incident happened at the facility that residents were not serve nutritious foods. During the visit, LPA Brown observed residents were served meatloaf, salad, bread, fruits and lemonade for lunch.
***Continuation in LIC9099C ***

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody Brown	TELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:	DATE: 04/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/13/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 56-AS-20230410111201

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: 04/13/2023

NARRATIVE

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Based on the evidence, the allegation that Food is not of nutritious value to meet the needs of residents is UNSUBSTANTIATED. A finding that the complaint is 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, therefore the allegation is unsubstantiated at this time.

An exit interview was conducted where this report, LIC9099 was discussed and provided to Licensee/Administrator Amelia Aladin.

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody Brown	TELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:	DATE: 04/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/13/2023

LIC9099 (FAS) - (06/04)

Page: 5 of 5