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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336426029
Report Date: 07/01/2024
Date Signed: 07/01/2024 04:00:38 PM


Document Has Been Signed on 07/01/2024 04:00 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 LIVINGFACILITY NUMBER:
336426029
ADMINISTRATOR:AMELIA ALADINFACILITY TYPE:
740
ADDRESS:3891 POLK STREETTELEPHONE:
(951) 689-6162
CITY:RIVERSIDESTATE: CAZIP CODE:
92505
CAPACITY:74CENSUS: 58DATE:
07/01/2024
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Licensee/Administrator Amelia AladinTIME COMPLETED:
04:05 PM
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On 07/01/2024 at 03:00 PM, Licensing Program Analyst (LPA) Melody Brown arrived at the facility, unannounced to conduct a Case Management visit. LPA Brown identified herself and met with Licensee/Administrator Amelia Aladin. LPA Brown informed Licensee/Administrator Aladin that this visit is being conducted to verify compliance with Health & Safety Code Section 1569.38.

Health & Safety Code 1569.38 requires the licensee to provide written notification to a resident, the residents' responsible party, if any, and the local long-term care ombudsman within 10 days from the date indicated on the accusation. The licensee is also required to post the accusation in a conspicuous place in the facility.

The licensee verified that she received the Accusation on 06/20/2024. The licensee was given 10 days from this date to notify, in writing, the residents, their responsible parties, and the ombudsman. The 10th day was 06/30/2024. During the tour of the facility on 07/01/2024, LPA observed that the licensee did post,as required by law, the accusations at the front office window near the main entrance of the facility and inside the facility near the Activity Area, Medication Room and Dining Room. Licensee/Administrator Aladin verbally confirmed that she has notified residents, informed residents' responsible parties and the Riverside County Long-Term Care Ombudsman (LTCO) Office in writing of the legal proceedings against the facility.

During today’s visit, LPA observed and/or licensee verbally confirmed that:
1.) The facility has posted accusations: #6224046403 and #6224046403B, as required by law.
2.) The facility has provided written notification as required by H&S Code 1569.38(b) to the residents/resident's responsible party and LTCO within the required 10 days. LPA retrieved the responsible party’s numbers and will be contacting them to verify written notifications have been received.

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

SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:
DATE: 07/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/01/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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