336426242-6-16-2021-18-AS-EMAN-C4FNXK-20210629105112

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 336426242
Report Date: 06/16/2021
Date Signed: 06/16/2021 04:53:46 PM

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
07/16/2020 and conducted by Evaluator Natalie Gayoso

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20200716140956

FACILITY NAME:	WELBROOK SENIOR LIVING ARLINGTON		FACILITY NUMBER:	336426242
ADMINISTRATOR:	PENDING		FACILITY TYPE:	740
ADDRESS:	7858 CALIFORNIA AVE		TELEPHONE:	(951) 687-2241
CITY:	RIVERSIDE	STATE: CA	ZIP CODE:	92504
CAPACITY:	140	CENSUS: 92	DATE:	06/16/2021
		UNANNOUNCED	TIME BEGAN:	10:15 AM
MET WITH:	Lori Spencer		TIME COMPLETED:	05:02 PM

ALLEGATION(S):

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Staff failed to seek timely medical attention for resident while in care
Resident sustained an injury while in care
Staff demonstrated inappropriate form of punishment towards a resident while in care
Staff failed to protect residents from harm while in care

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPAs) Natalie Gayoso and Anna Bueno arrived at the facility to conduct interviews and deliver findings for the above allegations. LPAs introduced themselves and discussed the purpose of today’s visit with Executive Director, Lori Spencer.

The investigation consisted of interviews and records review. The first allegation indicated staff failed to seek timely medical attention for resident while in care. LPAs interviewed Staff #2 (S2) who indicated that Resident #1 (R1)sustained an injury back on 6/25/2018 during an unwitnessed fall in the facility hallway. S2 stated staff called 911 and R1 was taken to Riverside Community Hospital. LPAs were provided with an incident report verifying R1 received medical attention in a timely manner. LPAs also verified a Special Incident Report (SIR) was submitted to the Department regarding incident.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Natalie Gayoso	TELEPHONE: (951) 290-1102
LICENSING EVALUATOR SIGNATURE:	DATE: 06/16/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2021

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-20200716140956

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: WELBROOK SENIOR LIVING ARLINGTON	FACILITY NUMBER: 336426242
	VISIT DATE: 06/16/2021

NARRATIVE

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The second allegation indicates resident sustained an injury while in care. Interview with S2 stated R1 had a unwitnessed fall that results in R1 obtaining an hematoma injury to the right of their face. LPAs reviewed SIR regarding injury and verified report stated fall was unwitnessed and R1 informed staff they had fallen and hit their head when confronted by staff.

The third allegation indicates staff demonstrated inappropriate form of punishment towards a resident while in care. Interviews with staff indicated they have never witnessed R1 being punished while in care. S2 stated R1 was transferred to Memory Care Unit due to progression in dementia and not as a form of punishment. LPAs reviewed R1's physician report and verified R1 is diagnosed with dementia.

The fourth allegation indicated staff failed to protect residents from harm while care. Interviews with staff indicated the facility has never failed in protecting residents from harm. S1 and S2 stated R1 was never assaulted nor sustained any injuries while in Memory Care Unit.

Based on interviews which were conducted, and records review, the above allegations are unsubstantiated. A finding of UNSUBSTANTIATED means 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.

No deficiencies were cited at this time.
An exit interview was conducted, and a copy of this report was reviewed and provided to the Executive Director

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Natalie Gayoso	TELEPHONE: (951) 290-1102
LICENSING EVALUATOR SIGNATURE:	DATE: 06/16/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2021

LIC9099 (FAS) - (06/04)

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