336426511-3-8-2023-56-AS-EMAN-CPVV5Q-20230313160820

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 336426511
Report Date: 03/08/2023
Date Signed: 03/08/2023 09:15:15 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 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
12/06/2022 and conducted by Evaluator Ryan Gardner

PUBLIC

COMPLAINT CONTROL NUMBER: 56-AS-20221206143918

FACILITY NAME:	AVISTA SENIOR LIVING MAGNOLIA		FACILITY NUMBER:	336426511
ADMINISTRATOR:	BLASIA LEE-LOLE		FACILITY TYPE:	740
ADDRESS:	737 MAGNOLIA AVE		TELEPHONE:	(951) 737-1600
CITY:	CORONA	STATE: CA	ZIP CODE:	92879
CAPACITY:	180	CENSUS: 160	DATE:	03/08/2023
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Blasia Lee-Lole- Administrator		TIME COMPLETED:	09:23 AM

ALLEGATION(S):

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Licensee neglect resulted in resident sustaining injuries while in care.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Ryan Gardner made an unannounced visit to the facility to conclude and issue findings for the investigation that was initiated on 12/13/2022. LPA stated the purpose of the visit and was granted entry and met with Administrator Blasia Lee-Lole.

The investigation was conducted by an IB Investigator which included a review of Resident R1’s facility records and medical records, interview with a medical social worker (MSW), interviews with four (4) facility staff (S1, S2, S3, S4), an interview with R1, and an interview with R1’s family member(R1FM).

For allegation, Licensee neglect resulted in resident sustaining injuries while in care:

It was alleged that on 12/3/2022 R1 fell due to neglect and sustained injuries.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 248-8222
LICENSING EVALUATOR NAME: Ryan Gardner	TELEPHONE: (951) 836-3180
LICENSING EVALUATOR SIGNATURE:	DATE: 03/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2023

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 56-AS-20221206143918

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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

FACILITY NAME: AVISTA SENIOR LIVING MAGNOLIA	FACILITY NUMBER: 336426511
	VISIT DATE: 03/08/2023

NARRATIVE

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During interview with R1, when asked about R1 injuries, R1 pointed to their face near their eyebrow. R1 stated that they could not remember how they sustained injuries and they could not remember the names any of the staff at the facility.

During interview with R1FM, R1FM stated that R1 could not remember details of how they sustained their injuries. R1FM stated that R1 has a condition that causes them to lose their balance. R1FM did not have any concerns of abuse or neglect from the facility.

During interview conducted with the MSW, the MSW stated that R1 was unclear how they sustained the injuries and R1 was not sure why they were at the hospital.

During interview staff S1, S1 stated that R1 had been found on their bedroom floor by S3. R1 appeared to be tangled in their wheelchair. S1 stated that R1 was not moved by staff due to unknown injuries and 911 was called immediately.

During interview with staff S2, S2 stated that R1 had difficulty walking, was a fall risk, and had therapy twice a week to help with daily living, balance, and mobility. S2 stated the facility would give R1 visual and verbal reminders of how to transitions to and from their wheelchair.

During interview with Staff S3, it was discovered that S3 was the staff that found R1 the day of the fall. R1 was found during a medication check. S3 found R1 on their bedroom floor near the restroom. S3 immediately called for backup from S1. R1 was not moved due to unknown injuries and 911 was called immediately. S3 stated that due to R1’s risk of fall, R1 was checked on every two (2) hours. R1 was very independent and would often decline help from S3.

During interview with S4, it was discovered that R1 had fallen prior this current incident. S4 stated that R1 had a condition that made it difficult for R1 to walk. R1 was defined as a fall risk, due to this the staff would assist R1 with wheelchair transfers and would provide assistance with their walker. The day R1 fell, 911 was called immediately due to R1 injuries.

During record review, it was discovered that R1 was taken to the hospital and treated for the injuries sustained due to the fall.

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 248-8222
LICENSING EVALUATOR NAME: Ryan Gardner	TELEPHONE: (951) 836-3180
LICENSING EVALUATOR SIGNATURE:	DATE: 03/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2023

LIC9099 (FAS) - (06/04)

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Control Number 56-AS-20221206143918

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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

FACILITY NAME: AVISTA SENIOR LIVING MAGNOLIA	FACILITY NUMBER: 336426511
	VISIT DATE: 03/08/2023

NARRATIVE

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Overall, during the investigation, there was not substantial evidence to collaborate the allegation.

Based on evidence obtained, the IB Investigator deemed the allegation listed above UNSUBSTANTIATED. A finding that the complaint is UNSUBSTANTIATED means 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.

During today’s visit, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations.

An exit interview was conducted, and this report (LIC9099) was discussed and provided to Administrator Blasia Lee-Lole, along with a copy of the appeal rights.

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 248-8222
LICENSING EVALUATOR NAME: Ryan Gardner	TELEPHONE: (951) 836-3180
LICENSING EVALUATOR SIGNATURE:	DATE: 03/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2023

LIC9099 (FAS) - (06/04)

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