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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336426029
Report Date: 12/10/2024
Date Signed: 12/10/2024 01:17:36 PM

Document Has Been Signed on 12/10/2024 01:17 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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:CALOAKS SENIOR LIVINGFACILITY NUMBER:
336426029
ADMINISTRATOR/
DIRECTOR:
AMELIA ALADINFACILITY TYPE:
740
ADDRESS:3891 POLK STREETTELEPHONE:
(951) 689-6162
CITY:RIVERSIDESTATE: CAZIP CODE:
92505
CAPACITY: 74TOTAL ENROLLED CHILDREN: 0CENSUS: 58DATE:
12/10/2024
TYPE OF VISIT:OfficeUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:Tim Dela CruzTIME VISIT/
INSPECTION COMPLETED:
01:25 PM
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On 12/10/24, Licensing Program Analyst (LPA) Magda Malcore met with Acting Administrator, Tim Dela Cruz at Community Care Licensing Division regional office to follow up on a substantiated complaint investigation.

On December 23, 2021, the Department concluded a complaint investigation regarding the allegation that staff neglect resulted in resident’s (R1) death. The licensee was cited for Health and Safety Code § 1569.269(a)(6) Enumerated rights; severability.

At the time of the complaint visit on December 23, 2021, an immediate civil penalty of $500.00 was issued and the licensee was informed that an additional civil penalty might be assessed based on Health and Safety Code § 1569.49(e).

The Department has concluded an analysis and has determined that a civil penalty is warranted for a violation that the Department determines resulted in the death of a resident. This is evidenced by the facility staff failing to meet R1 needs and properly supervise R1. Following an unwitnessed fall, R1 laid outside for hours and died of hyperthermia due to environmental heat exposure.

Today, 12/10/2024, the Department will be issuing a civil penalty per Health and Safety Code § 1569.49(e) for a violation that the Department constitutes as resulting in R1’s death in the amount of $15,000.00. However, since an immediate civil penalty of $500.00 was previously issued on December 23, 2021, the amount of the civil penalty issued today will be $14,500.00.



Exit interview conducted. A copy of the report issued. Appeal rights provided to Acting Administrator Dela Cruz and signature on this report acknowledges receipt of the appeal rights, found on page two of LIC 421D.
Karen ClemonsTELEPHONE: (951) 248-0349
Magda MalcoreTELEPHONE: 951-248-0316
DATE: 12/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/10/2024
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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