336426511-9-8-2022-56-AS-EMAN-CJFUSY-20220920155104

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 336426511
Report Date: 09/08/2022
Date Signed: 09/08/2022 01:07:31 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
09/07/2022 and conducted by Evaluator Ryan Gardner

PUBLIC

COMPLAINT CONTROL NUMBER: 56-AS-20220907155929

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: 125	DATE:	09/08/2022
		UNANNOUNCED	TIME BEGAN:	10:03 AM
MET WITH:	Blasia Lee-Lole- Administrator		TIME COMPLETED:	01:27 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility has pests.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Ryan Gardner arrived at the facility unannounced to initiate and deliver findings for the above complaint allegation. LPA met with Administrator Blasia Lee-Lole and explained the reason for the visit.

During today’s visit, LPA Gardner toured the facility, conducted interviews with residents, conducted interviews with staff, and reviewed facility documentation.

For allegation, Facility has pests:

The facility provided LPA with the housekeeping/laundry schedule for each resident. LPA discovered that the facility housekeeping staff cleans the resident’s bedrooms once a week. LPA was informed that the resident’s bedrooms will be cleaned more often by housekeeping staff if a resident needs additional cleaning. LPA discovered that the resident’s sheets and bedding are cleaned at minimum every two weeks and will be cleaned more often if needed. LPA Gardner entered eleven (11) of the twelve (12) resident’s bedrooms that were interviewed.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Ryan Gardner	TELEPHONE: (951) 836-3180
LICENSING EVALUATOR SIGNATURE:	DATE: 09/08/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2022

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 2

Control Number 56-AS-20220907155929

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: 09/08/2022

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

LPA did not observe any pests in the residents bedrooms. LPA did not observe any pests in the main gathering areas within the facility. The facility has Western Exterminator Company treat the interior and the exterior of the facility for pests monthly. During documentation review it was discovered that on 8/30/22, R1’s bedroom was treated by Western Exterminator Company after complaints of pests in the bedroom. During documentation review and interview with staff and interview with R1 it was discovered that on 9/5/22, the Administrator purchased and treated R1’s bedroom with a bed bug/flee fogger.

Based on information found and discovered, LPA found 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, therefore the allegation is deemed UNSUBSTANTIATED.

An exit interview was conducted, and this report was discussed and provided to Administrator Blasia Lee-Lole, along with a copy of the appeal rights.

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Ryan Gardner	TELEPHONE: (951) 836-3180
LICENSING EVALUATOR SIGNATURE:	DATE: 09/08/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 2