336426505-1-30-2024-18-AS-RSTS-D4LLVR-20240423090556

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 336426505
Report Date: 01/30/2024
Date Signed: 01/30/2024 12:41:50 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 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
03/15/2021 and conducted by Evaluator Stephanie Martinez

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20210315130523

FACILITY NAME:	STONEWALL GARDENS ASSISTED LIVING		FACILITY NUMBER:	336426505
ADMINISTRATOR:	BOEDDEKER, ALLEN		FACILITY TYPE:	740
ADDRESS:	2150 N PALM CANYON DR		TELEPHONE:	(760) 548-0970
CITY:	PALM SPRINGS	STATE: CA	ZIP CODE:	92262
CAPACITY:	35	CENSUS: 24	DATE:	01/30/2024
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Lauren Kabakoff, Interim-Administrator		TIME COMPLETED:	12:45 PM

ALLEGATION(S):

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Resident sustained unexplained bruising while in care.
Staff did not safeguard resident's personal property.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA), Stephanie Martinez, conducted an unannounced visit to the facility to conclude the investigation into the above allegations. The LPA met with Interim Administrator, Lauren Kabakoff, and informed her of the purpose for the visit.

A report was received by the Department alleging Resident One (R1) was observed with unexplained bruising to their neck on or around March 15, 2021. Administrator Chad Boeddeker was interviewed and reported R1 was observed with bruising; however, he stated R1 returned to the facility from a hospitalization with the injuries. He reported R1 would sustain bruises occasionally due to being a fall risk. He reported R1 would not request staff assistance when ambulating. Resident records were obtained on 03/23/2021. R1's Physician's Report (California) was reviewed; the document revealed the resident had no motor impairment or paralysis, was not confused or disoriented, and had no history of skin conditions or breakdown. An interview with R1 could not be conducted due to the resident passing away in March 2021. Additional staff and resident interviews could provide no additional information regarding the matter. Therefore, due to insufficient

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Rikesha Stamps	TELEPHONE: (951) -212-0616
LICENSING EVALUATOR NAME: Stephanie Martinez	TELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:	DATE: 01/30/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2024

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-20210315130523

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: STONEWALL GARDENS ASSISTED LIVING	FACILITY NUMBER: 336426505
	VISIT DATE: 01/30/2024

NARRATIVE

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information, this allegation is deemed UNSUBSTANTIATED at this time.

In addition, a report was received by the Department alleging facility staff lost R1's wallet and glasses. Staff and resident interviews reported R1 was observed to utilize glasses. One staff interview reported overhearing R1 mention they had lost their wallet; however, the staff member could not recall the circumstances surrounding the incident. An interview with R1 could not be conducted due to the resident passing away in March 2021. Additional interviews could not provide any information to corroborate or refute the allegation. Therefore, due to insufficient information, this allegation is deemed UNSUBSTANTIATED at this time.

A finding that the complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violations occurred.

This report was reviewed with Interim-Administrator Kabakoff and a copy was provided.

SUPERVISOR'S NAME: Rikesha Stamps	TELEPHONE: (951) -212-0616
LICENSING EVALUATOR NAME: Stephanie Martinez	TELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:	DATE: 01/30/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2024

LIC9099 (FAS) - (06/04)

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