336426511-4-15-2022-18-AS-EMAN-CHFLPM-20220819085611

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 336426511
Report Date: 04/15/2022
Date Signed: 04/15/2022 03:13:53 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
01/05/2022 and conducted by Evaluator Jennifer Semin

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20220105112909

FACILITY NAME:	AVISTA SENIOR LIVING MAGNOLIA		FACILITY NUMBER:	336426511
ADMINISTRATOR:	MONIQUE DEL JUNCO		FACILITY TYPE:	740
ADDRESS:	737 MAGNOLIA AVE		TELEPHONE:	(951) 737-1600
CITY:	CORONA	STATE: CA	ZIP CODE:	92879
CAPACITY:	180	CENSUS: 116	DATE:	04/15/2022
		UNANNOUNCED	TIME BEGAN:	10:15 AM
MET WITH:	Alexis Brown		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Staff do not change residents timely
Staff do not answer resident call buttons timely
Resident is not being bathed
Resident developed a pressure injury while in care

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Jennifer Semin conducted an unannounced visit to deliver the findings for the above complaint allegations. LPA met with Health Services Director, Alexis Brown.

The investigation consisted of interviews and review of records. The first allegation, Staff do not change residents timely. Relevant party (RP) stated staff do not change Resident 1 (R1) “for hours”. Staff stated they change residents every 2 hours and as needed. Residents, requiring incontinent care, stated staff change them every 2 hours, assist them regularly and as needed.
The second allegation, Staff do not answer resident call buttons timely. Relevant party (RP) stated call button wait time is almost 4 hours. Staff stated they have a response time within 15 minutes to call buttons. Residents interviewed stated staff respond quickly to their call buttons. LPA observed staff call button response time to be between 1-3 minutes.
The third allegation, Resident is not being bathed. Relevant party (RP) stated staff are not bathing R1. Staff stated all residents requiring assistance with showering are bathed twice a week. Staff stated

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Jennifer Semin	TELEPHONE: (951) 473-7024
LICENSING EVALUATOR SIGNATURE:	DATE: 04/15/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2022

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 4

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
01/05/2022 and conducted by Evaluator Jennifer Semin

COMPLAINT CONTROL NUMBER: 18-AS-20220105112909

FACILITY NAME:	AVISTA SENIOR LIVING MAGNOLIA		FACILITY NUMBER:	336426511
ADMINISTRATOR:	MONIQUE DEL JUNCO		FACILITY TYPE:	740
ADDRESS:	737 MAGNOLIA AVE		TELEPHONE:	(951) 737-1600
CITY:	CORONA	STATE: CA	ZIP CODE:	92879
CAPACITY:	180	CENSUS: 116	DATE:	04/15/2022
		UNANNOUNCED	TIME BEGAN:	10:15 AM
MET WITH:	Alexis Brown		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Resident developed a rash while in care

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Jennifer Semin conducted an unannounced visit to deliver the findings for the above complaint allegations. LPA met with Health Services Director Alexis Brown.

The investigation consisted of interviews and review of records. The allegation, Resident developed a rash while in care. Relevant party (RP) stated Resident 1 (R1) developed a rash while in care and the facility did not notify RP of the rash. Staff stated R1 did develop a fungal rash while in care. Staff stated they did verbalize this to the nurse and family. Staff stated at that time, R1 was referred to hospice. LPA did not observe facility documentation indicating R1 had developed a rash.
Based on interviews and documentation, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6 & Chapter 1) is being cited on the attached LIC9099D.
An exit interview was conducted where this report, LIC9099D, and appeal rights were discussed and provided to Ms. Brown.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Jennifer Semin	TELEPHONE: (951) 473-7024
LICENSING EVALUATOR SIGNATURE:	DATE: 04/15/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 18-AS-20220105112909

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: AVISTA SENIOR LIVING MAGNOLIA	FACILITY NUMBER: 336426511
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/15/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 04/16/2022 Section Cited CCR 87466	1 2 3 4 5 6 7	Observation of the Resident: The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning & that appropriate assistance is provided when such observation reveals unmet needs. When changes such as unusual weight gains or losses or deterioration of mental ability or a	1 2 3 4 5 6 7	Licensss shall read the regulation in it's entirety, submit a statement of understanding and conduct staff training this regulation and submit it to CCL by the POC due date of 4/16/2022.
	8 9 10 11 12 13 14	physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician & the resident's responsible person, if any. This requirement was not met as evidenced by: Staff did not notify Resident 1's physician & the resident's responsible person once the rash was observed. This poses an immediate risk to the health and safety of residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Jennifer Semin	TELEPHONE: (951) 473-7024
LICENSING EVALUATOR SIGNATURE:	DATE: 04/15/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2022

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 18-AS-20220105112909

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: AVISTA SENIOR LIVING MAGNOLIA	FACILITY NUMBER: 336426511
	VISIT DATE: 04/15/2022

NARRATIVE

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(R1) was scheduled to be showered twice a week but was showered at least once a week due to R1’s refusal. Residents interviewed stated staff assist them with showers twice a week.
The fifth allegation, Resident developed a pressure injury while in care. Relevant party (RP) stated R1 developed a pressure injury on the side of their leg. Staff stated R1 did not have any pressure injuries. LPA observed R1's documents and they did not indicate R1 had a pressure injury.
Based upon interviews and information gathered, and although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED at this time.

An exit interview was conducted where this report was discussed and provided to Ms. Brown.

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Jennifer Semin	TELEPHONE: (951) 473-7024
LICENSING EVALUATOR SIGNATURE:	DATE: 04/15/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2022

LIC9099 (FAS) - (06/04)

Page: 4 of 4