336426029-7-20-2022-56-AS-EMAN-CK7TBC-20221014143454

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 336426029
Report Date: 07/20/2022
Date Signed: 07/20/2022 05:06:54 PM

Substantiated

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
07/13/2022 and conducted by Evaluator Melody Brown

PUBLIC

COMPLAINT CONTROL NUMBER: 56-AS-20220713171313

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: 54	DATE:	07/20/2022
		UNANNOUNCED	TIME BEGAN:	04:30 PM
MET WITH:	Wellness Director Melissa Bridges		TIME COMPLETED:	05:30 PM

ALLEGATION(S):

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Facility has roaches.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Melody Brown arrived unannounced at the facility to deliver findings for the allegation listed above. LPA Brown was greeted and granted entry by Wellness Director Melissa Bridges and LPA Brown explained the purpose of the visit. The investigation consisted of observation, interviews and a review of pertinent documentation.

Through the information gathered during the investigation, it was confirmed by observation, documents review and interviews that there are still roaches in the facility after cleaning and spraying for them was conducted. Although the facility is taking action for the roaches, as Administrator Aladin indicated, it appears that there is not sufficient treatment being done by the facility’s contracted exterminator to aggressively rid the roaches. Also, Administrator Aladin reported that the facility will have a sufficient follow up to their contracted exterminators to control the roaches in the building. Interviews with staff also indicated knowledge of roaches at the facility.
*** Continuation in LIC9099C ***

Substantiated

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: 07/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2022

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 56-AS-20220713171313

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: 07/20/2022

NARRATIVE

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LPA Brown toured the facility with Wellness Director Melissa Bridges and Staff 5 (S5) last 07/14/2022 at around 10:15 AM and LPA Brown observed dead roach at resident room #5, room #7, and room #18 and roach droppings at room #5, room #7, room#10, room #11 and room #18. Also, during the visit, LPA Brown observed the facility’s contracted exterminator however, per review of their Monthly Maintenance Control Spray, LPA Brown observed only 10 resident rooms were sprayed/serviced. LPA Brown recommended to Wellness Director Melissa Bridges that all rooms must be sprayed/serviced not just 10 selected resident rooms. Wellness Director Bridges reported that they have a plan with the contracted exterminator to address the issue which is to increase the days of their contracted exterminator from monthly to twice a month and that all resident rooms must be sprayed.

Based on observation and interviews, the allegation of Facility has roaches is SUBSTANTIATED. A finding that the complaint is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met.

An exit interview was conducted and a copy of this report, LIC9099, LIC9099D and appeal rights was discussed and provided to Wellness Director Melissa Bridges.

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody Brown	TELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:	DATE: 07/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2022

LIC9099 (FAS) - (06/04)

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Control Number 56-AS-20220713171313

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/20/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 07/21/2022 Section Cited CCR 87303(a)	1 2 3 4 5 6 7	87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety... This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Licensee stated to call exterminator within 24 hours to have exterminator services performed on the inside and outside of the home and a plan of procedure shall be submitted to LPA Brown no later than COB 07/21/2022 regarding the roaches observed at the facility.
	8 9 10 11 12 13 14	Based on observation, interview and record review, the Licensee did not comply with the section cited above by not aggressively addressing the roaches issue at the facility which poses immediate health, safety and personal rights risks to resident in care.	8 9 10 11 12 13 14	LPA Brown will also receive all receipts of services for the roaches service/treatment once performed no more than 24 hours after services performed.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody Brown	TELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:	DATE: 07/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2022

LIC9099 (FAS) - (06/04)

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