336426029-2-22-2022-18-AS-EMAN-CDLT64-20220418142631

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 336426029
Report Date: 02/22/2022
Date Signed: 02/22/2022 02:31:38 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
12/28/2021 and conducted by Evaluator Stephanie Williams

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20211228150408

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: 57	DATE:	02/22/2022
		UNANNOUNCED	TIME BEGAN:	12:00 PM
MET WITH:	Amelia Aladin & Melissa Bridges		TIME COMPLETED:	01:30 PM

ALLEGATION(S):

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Staff handling resident in a rough manner.
Facility is unclean.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Stephanie Williams made an unannounced visit to the facility in order to deliver findings for the above allegations. LPA Williams identified herself to Administrator, Amelia Aladin, and Wellness Director, Melissa Bridges, who were also informed of the purpose of the visit. The investigation consisted of direct observations, records review, and interviews with staff and residents.

In regards to allegation #1, LPA Williams was unable to interview Resident #1 (R1) due to R1 passing away in January of 2022. LPA Williams interviewed Resident #2 (R2) and Resident #3 (R3) who both denied that staff members are handling residents in a rough manner. LPA Williams interviewed Staff #1 (S1), Staff #2 (S2) and Staff #3 (S3) who all denied mishandling any resident and denied having knowledge of other staff members mishandling any resident. Due to lack of evidence to corroborate the allegation, the allegation is unsubstantiated.

In regards to allegation #1, LPA Williams inspected several bedrooms throughout the facility. LPA Williams

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: 02/22/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/22/2022

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

LIC9099 (FAS) - (06/04)

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Control Number 18-AS-20211228150408

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: 02/22/2022

NARRATIVE

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observed in one bedroom, there was what appeared to be an insect crawling on a wall. LPA Williams interviewed S1, S2, and S3, who all stated that the facility receives monthly extermination services through a reputable extermination company. LPA Williams observed several Service Inspection Report's from the company from December 2021 through February 2022. The reports indicated that the company serviced the facility for roaches, ants, spiders, etc. S1 also stated that the company uses a less-intense chemical approach to service the facility due to the facility's elderly population and sensitivity to harsh chemicals. S1 stated that the facility is working collaboratively with the extermination company to address the insect issues .

Based on evidence obtained during today’s visit, LPA Williams has determined that the above allegations are UNSUBSTANTIATED; meaning that 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.

An exit interview was conducted where this report (LIC 9099) was discussed and a copy was provided to Bridges at the conclusion of the visit.

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 248-0337
LICENSING EVALUATOR NAME: Stephanie Williams	TELEPHONE: (951) 248-0317
LICENSING EVALUATOR SIGNATURE:	DATE: 02/22/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/22/2022

LIC9099 (FAS) - (06/04)

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