336426029-11-18-2021-18-AS-EMAN-CDPSHJ-20220421135337

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 336426029
Report Date: 11/18/2021
Date Signed: 11/18/2021 12:20:24 PM

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
RIVERSIDE, CA 92507

This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/08/2021 and conducted by Evaluator Stephanie Williams

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20211108145355

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: 62	DATE:	11/18/2021
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Amelia Aladin		TIME COMPLETED:	12:30 PM

ALLEGATION(S):

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Staff does not ensure resident's special dietary needs are met
Staff does not keep the facility free of insects
Staff does not keep the facility clean
Staff did not ensure that resident's diapering needs were met
Insufficient staffing to meet resident needs

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Stephanie Williams made an unannounced visit to the facility in order to initiate a complaint investigation into the above allegations. LPA Williams identified herself to Administrator, Amelia Aladin, and also discussed the purpose of the visit with Aladin. The investigation consisted of records review, direct observation, and interviews with staff and residents.

In regards to allegation #1, staff does not ensure resident's special dietary needs are met, LPA Williams interviewed Staff #1 (S1), Staff #2 (S2), Staff #3 (S3), Staff #4 (S4), and Staff #5 (S5), who all stated that residents' special dietary needs are being met. S5 stated that some residents require mechanical, puree, and diabetic meal plans, and that they prepare the meals in accordance to residents' needs. S5 stated that they follow the facility's meal menu when preparing meals, which usually consists of a variety of proteins and vegetables. LPA Williams interviewed Resident #1 (R1), who stated that they require a diabetic meal plan. R1 stated that the facility provides meals in accordance to their special dietary needs, which usually consist of chicken, beef, fish and vegetables. LPA reviewed the facility's meal menu and list of residents special dietary

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 248-0337
LICENSING EVALUATOR NAME: Stephanie Williams	TELEPHONE: (951) 248-0317
LICENSING EVALUATOR SIGNATURE:	DATE: 11/18/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2021

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-20211108145355

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: 11/18/2021

NARRATIVE

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plans.

In regards to allegation #2, staff does not keep the facility free of insects, LPA Williams observed several areas of the facility for any visible insects; however, LPA Williams did not observe any insects. LPA Williams interviewed S1, S2, S3, S4, and S5, who all stated that the facility utilizes an extermination control company, who comes to service the facility as often as every month. LPA Williams interviewed R1, Resident #2 (R2), Resident #3 (R3), and Residetn #4 (R4), who all denied that the facility currently has insects. LPA Williams reviewed service records for the facility provided by Western Exterminator Company, who serviced the facility for insects as recently as of 11/11/2021.

In regards to allegation #3, staff does not keep the facility clean, LPA Williams observed several staff members cleaning the facility areas upon arrival. LPA Williams inspected resident rooms and the facility's kitchen areas, which were kempt and kept free of debris. LPA Williams interviewed R1, R2, R3, and R4, who all stated that the facility is usually clean. R3 stated that staff members "are always cleaning." LPA Williams interviewed S1, S2, S3, S4, and S5, who all stated that the facility has a dedicated housekeeper and caregivers also assist in cleaning the facility as well.

In regards to allegation #4, staff did not ensure that resident's diapering needs were met, LPA Williams interviewed R2, who stated that they do not recall being left in a soiled diaper for a long period of time. R2 stated that staff members check on R2 often and R2 usually verbalizes to staff members when they need to be changed. LPA Williams interviewed S1, who stated than an internal investigation was conducted into the allegation that R2 was left in a soiled diaper for a long period of time. S1 stated that when R2 was asked if their diaper was changed, R2 responded that their diaper was changed by Staff #6 (S6) that day. S1 stated that the facility's incontinence protocol is that staff check residents every 2 to 4 hours; however, S1 stated that most residents are able to verbalize when they need to be changed. S1 stated that to her knowledge, staff members are following incontinence care protocol. LPA Williams interviewed R1, who also requires incontinence care, and they stated that the staff "are good" when their diaper needs to be changed. R1 denied that they were ever left in a soiled diaper for a long period of time.

In regards to allegation #5, insufficient staffing to meet resident needs, LPA Williams interviewed R1, R2, R3, and R4, who all stated that they believe the facility is adequately staffed to meet their needs. All residents interviewed denied feeling neglect and emphasized that staff members are attentive to them. LPA Williams

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 248-0337
LICENSING EVALUATOR NAME: Stephanie Williams	TELEPHONE: (951) 248-0317
LICENSING EVALUATOR SIGNATURE:	DATE: 11/18/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 18-AS-20211108145355

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: 11/18/2021

NARRATIVE

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interviewed S1, S2, and S3, who all stated that there are about ten staff members during the day shuft and two staff members during the noc shift. All staff members interviewed stated that they believe all residents' needs are being met and the facility is adequately staffed. Of all the staff members interviewed, none reported that they felt overwhelmed with their duties at the facility. LPA Williams reviewed the facility's staff roster and schedule.

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 248-0337
LICENSING EVALUATOR NAME: Stephanie Williams	TELEPHONE: (951) 248-0317
LICENSING EVALUATOR SIGNATURE:	DATE: 11/18/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2021

LIC9099 (FAS) - (06/04)

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