336426029-7-14-2022-56-AS-EMAN-CHTSR7-20220831140552

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 336426029
Report Date: 07/14/2022
Date Signed: 07/14/2022 09:10:20 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
05/11/2022 and conducted by Evaluator Melody Brown

PUBLIC

COMPLAINT CONTROL NUMBER: 56-AS-20220511101248

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: 58	DATE:	07/14/2022
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Administrator Amelia Aladin		TIME COMPLETED:	12:45 PM

ALLEGATION(S):

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Resident sustained multiple injuries while in care due to lack of supervision from staff.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Melody Brown made an unannounced visit to the facility 07/14/2022 at 09:30 AM in order to deliver the findings for the above allegation. LPA Brown identified herself to Wellness Director, Melissa Bridges, who was also informed of the purpose of the visit. Administrator Amelia Aladin was contacted and arrived during the visit. The investigation consisted of direct observations, records review, and interviews with staffs and residents.

LPA Brown interviewed Staff #1 (S1), Staff #2 (S2), Staff #3 (S3), Staff #4 (S4), Staff #5 (S5), and Staff #6 (S6) who all denied that the facility failed to supervise Resident #1 (R1) which resulted in R1 sustaining multiple injuries. S1, S2 and S3 all stated that when R1 fell on the floor, they immediately call paramedics to assessed R1 and R1 was transported to the nearest hospital. S4, S5, S6 and S7 all denied that R1 has no supervision that resulted to multiple injuries. *** Continuation in LIC9099C ***

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody Brown	TELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:	DATE: 07/14/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2022

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-20220511101248

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: 07/14/2022

NARRATIVE

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Interviewed with Resident #1 (R1), Resident #2 (R2), Resident #3 (R3), Resident #5 (R5), Resident #7 (R7), Resident #8 (R8) and Resident #9 (R9) all indicated that they have sufficient supervision from all staff at the facility and all of them denied being neglected by staff. Additionally, LPA Brown reviewed facility’s Staff Communication Log and Hospital Patient Visit Summary Report and LPA Brown observed no indications of staff lack of supervision to residents at the facility and LPA Brown noted appropriate protocols were followed upon knowing that R1 fell.

Based on evidence obtained during the investigation, LPA Brown has determined that the allegation Resident sustained multiple injuries while in care due to lack of supervision from staff is 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 Administrator Amelia Aladin at the conclusion of the visit.

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody Brown	TELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:	DATE: 07/14/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2022

LIC9099 (FAS) - (06/04)

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