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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 336426029
Report Date: 05/12/2021
Date Signed: 05/19/2021 09:16:10 AM



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
RIVERSIDE, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/12/2021 and conducted by Evaluator Stephanie Torres
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20210412122337
FACILITY NAME:CALOAKS SENIOR LIVINGFACILITY NUMBER:
336426029
ADMINISTRATOR:AMELIA ALADINFACILITY TYPE:
740
ADDRESS:3891 POLK STREETTELEPHONE:
(951) 689-6162
CITY:RIVERSIDESTATE: CAZIP CODE:
92505
CAPACITY:74CENSUS: 62DATE:
05/12/2021
UNANNOUNCEDTIME BEGAN:
01:52 PM
MET WITH:Amelia Aladin, AdministratorTIME COMPLETED:
02:02 PM
ALLEGATION(S):
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Staff did not keep the facility free from pests
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Stephanie Torres, contacted the facility via telephone, due to COVID-19, to deliver the findings of the investigation into the above allegation. The LPA identified herself and discussed the purpose of the call with Administrator, Amelia Aladin.

Regarding the allegation, "Staff did not keep the facility free from pests," it was alleged Resident One (R1) was observed to have cockroaches crawling on top of them and on their food tray on April 09, 2021. The LPA initiated the investigation on April 20, 2021; the LPA toured the facility, conducted resident interviews, reviewed records and took copies of pertinent information. At least thirteen (13) cockroaches, at different growth stages, were observed throughout the facility and inside of resident furniture. Records review was conducted; an invoice from a pest control company revealed the facility has addressed the insect infestation in the past. Third party interviews revealed the facility has not arranged for interior fumigation in five (5) or more months. R1 was interviewed and corroborated the allegation. Therefore based on interviews and observation, this allegation is deemed SUBSTANTIATED. A finding that the complaint is substantiated means that the allegation is valid
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Stephanie TorresTELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:

DATE: 05/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2021
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-20210412122337
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
RIVERSIDE, CA 92507
FACILITY NAME: CALOAKS SENIOR LIVING
FACILITY NUMBER: 336426029
VISIT DATE: 05/12/2021
NARRATIVE
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because the preponderance of the evidence standard has been met. A citation will be issued in accordance with the California Code of Regulations (Title 22, Division 6, Chapter 8).

An exit interview was conducted; this report was reviewed with Aladin and a copy was provided, along with the following reports: LIC 9099D, LIC 811 and Appeal Rights.
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Stephanie TorresTELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:

DATE: 05/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 18-AS-20210412122337
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
RIVERSIDE, CA 92507

FACILITY NAME: CALOAKS SENIOR LIVING
FACILITY NUMBER: 336426029
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/12/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/17/2021
Section Cited
CCR
87303(a)
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MAINTENANCE AND OPERATION: The facility shall be clean, safe, sanitary ...at all times. Maintenance shall include provision of maintenance services & procedures for the safety and well-being of residents, employees and visitors. This requirement was not met as evidenced by: Based on interviews &
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The Administrator agreed to provide proof of fumigation services to the Department by the POC due date.
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observation, the licensee did not ensure the facility was safe and sanitary for residents in care. At least 13 cockroaches were observed throughout the facility & inside of resident furniture. R1 was interviewed & corroborated the allegation. This posed a health & personal rights risk to the resident 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.
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Stephanie TorresTELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:

DATE: 05/12/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 3