336426029-4-14-2022-56-AS-EMAN-CDWRLU-20220428130745

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 336426029
Report Date: 04/14/2022
Date Signed: 04/14/2022 04:16:01 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
, CA 92507

This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/09/2022 and conducted by Evaluator Stephanie Williams

PUBLIC

COMPLAINT CONTROL NUMBER: 56-AS-20220309134608

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: 60	DATE:	04/14/2022
		UNANNOUNCED	TIME BEGAN:	04:00 PM
MET WITH:	Melissa Bridges		TIME COMPLETED:	04:20 PM

ALLEGATION(S):

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Neglect of a resident which resulted in the resident sustaining injuries
Residents were overmedicated by staff
Facility is not kept in a sanitary condition
Facility did not provide resident with meals
Resident's hygiene needs were not met
Staff fraudulently signed documents on resident's behalf

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 Wellness Coordinator, Melissa Bridges, who was 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 interviewed Staff #1 (S1), Staff #2 (S2), and Staff #3 (S3), who all denied that the facility neglected Resident #1 (R1) which resulted in R1 sustaining injuries. S1 and S2 both stated that R1 does not currently have any injuries besides a rash. S1, S2, and S3 all denied that R1 currently has any wounds. LPA Williams interviewed Witness #1 (W1) and Witness #2 (W2) who also denied the facility neglected R1 which resulted in R1 sustaining injuries. W2 stated that R1 does not have any injuries besides a rash, which R1's hospice agency is currently treating. Additionally, LPA Williams interviewed R1, who denied

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Stephanie Williams	TELEPHONE: (951) 201-0159
LICENSING EVALUATOR SIGNATURE:	DATE: 04/13/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/13/2022

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 56-AS-20220309134608

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
, CA 92507

FACILITY NAME: CALOAKS SENIOR LIVING	FACILITY NUMBER: 336426029
	VISIT DATE: 04/14/2022

NARRATIVE

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sustaining any injuries as a result of neglect by the facility. R1 stated that they do not feel neglected.

In regards to allegation #2, LPA Williams interviewed S1, S2, S3, who denied that residents are being overmedicated. S1 and S2 both stated that R1's medications are continuously audited by R1's hospice agency. S2 also stated that other residents' medications are audited frequently by the facility's medication technicians. S1 and S2 stated that residents' medications are being dispensed appropriately and in accordance with physician orders. LPA Williams interviewed W2, who stated that R1's medications are audited and W2 has not observed any discrepancy with R1's medication administration. W2 denied that R1, or other residents, appeared overmedicated. LPA Williams interviewed R1, Resident #2 (R2), and Resident #3 (R3), who all denied feeling overmedicated or unreasonably lethargic/disoriented while at the facility.

In regards to allegation #3, LPA Williams inspected several areas of the facility. LPA Williams did not observe the facility to be unsanitary or malodorous. LPA Williams interviewed S1, S2, and S3, who all denied that the facility is not kept in a sanitary condition. S1, S2, and S3, stated that facility staff clean the facility on a daily basis. LPA Williams interviewed W1 and W2, who both denied that the facility is not kept in sanitary conditions. LPA Williams also interviewed R1, R2, and R3, who all denied that the facility is not kept in sanitary conditions. R2 and R3 stated that the facility staff members clean the facility frequently.

In regards to allegation #4, LPA Williams interviewed S1, S2, and S3, who all denied that the facility is not providing residents with meals. S1 and S2 stated that all residents, including R1, receive three meals a day. S1, S2, and S3, stated that R1 is directly fed by the facility staff members. At the time of visit, LPA Williams observed that S3 was feeding R1. LPA Williams interviewed W2, who stated that they believe R1 is being provided with meals. W2 stated that there appeared to be no changes in R1's weight or appearance. Additionally, LPA Williams interviewed R1, R2, and R3, who all stated that they receive three meals a day.

In regards to allegation #5, LPA Williams interviewed S1, S2, and S3, who all denied that residents hygiene needs are not being met. S1, S2, and S3, stated that facility staff bathe residents or provide assistance with showering to residents on their scheduled days. S1, S2, and S3 also stated that R1 was bathed by R1's hospice agency, in addition to baths provided by facility staff. LPA Williams interviewed W1 and W2 who both denied that R1's hygiene needs were not being met. LPA Williams also interviewed R1, R2, and R3, who all

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Stephanie Williams	TELEPHONE: (951) 201-0159
LICENSING EVALUATOR SIGNATURE:	DATE: 04/14/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2022

LIC9099 (FAS) - (06/04)

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Control Number 56-AS-20220309134608

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
, CA 92507

FACILITY NAME: CALOAKS SENIOR LIVING	FACILITY NUMBER: 336426029
	VISIT DATE: 04/14/2022

NARRATIVE

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stated that the facility does meet the residents personal hygiene needs.

In regards to allegation #6, LPA Williams interviewed S1 and S2, who both denied that facility staff fraudulently signed documents on resident's behalf. Both S1 and S2 stated that R1 is his own responsible party and requested that W1 sign R1's paperwork and make decisions on behalf of R1. LPA Williams interviewed R1, who confirmed that they requested W1 to be R1's decision maker and allowed W1 to sign for R1's paperwork. LPA Williams interviewed W1 who denied that they were coerced to sign any documents on behalf of R1. W1 stated that R1 requested that W1 sign R1's documents.

Based on evidence obtained during the investigation, 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) 202-6356
LICENSING EVALUATOR NAME: Stephanie Williams	TELEPHONE: (951) 201-0159
LICENSING EVALUATOR SIGNATURE:	DATE: 04/14/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2022

LIC9099 (FAS) - (06/04)

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