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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 336426511
Report Date: 04/10/2025
Date Signed: 04/10/2025 03:01:51 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
11/01/2024 and conducted by Evaluator Melody Brown
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20241101162150
FACILITY NAME:AVISTA SENIOR LIVING MAGNOLIAFACILITY NUMBER:
336426511
ADMINISTRATOR:BLASIA LEE-LOLEFACILITY TYPE:
740
ADDRESS:737 MAGNOLIA AVETELEPHONE:
(951) 737-1600
CITY:CORONASTATE: CAZIP CODE:
92879
CAPACITY:180CENSUS: 104DATE:
04/10/2025
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Executive Director Andrea PerezTIME COMPLETED:
03:15 PM
ALLEGATION(S):
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Unlawful Eviction.
INVESTIGATION FINDINGS:
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On 04/10/2025 at 02:00 PM, Licensing Program Analyst (LPA) Melody Brown met with Executive Director (ED) Andrea Perez at Community Care Licensing Division (CCLD) Adult and Senior Care (ASC) San Bernardino (SB) Regional Office (RO) to deliver the findings of the above allegation. LPA Brown explained the purpose of the requested Office Visit. The investigation consisted of observation, records review and interviews with relevant parties.

The investigation was conducted by LPA Melody Brown which consisted of observation, review of records and interviews with relevant parties. The allegation indicates Unlawful Eviction. During the investigation, LPA Brown was not able to obtain sufficient evidence to corroborate the allegation. LPA Brown interviewed Resident # 1 (R1) and R1 stated that R1 received a 30 Day Eviction Notice on about 11/2024 but R1 stated that R1 still lives at the facility and was never evicted. Documents review indicated that R1's self-responsible and signed the Admission Agreement - Respite on 05/13/2024 but no new Facility Admission Agreement was signed by R1 that does not indicate "Respite Stay Only." ***Continuation in LIC9099C***
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 04/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2025
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-20241101162150
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: 04/10/2025
NARRATIVE
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In addition, LPA Brown noted that R1 was admitted to the facility on 05/13/2024 on Respite Care which means a short-term, time-limited basis and interview with R1 revealed that R1 refused to sign the facility's new Admission Agreement that does not indicate "Respite Stay Only" until R1's family member agrees. Interview with Staff #1 (S1) indicated that they requested R1 to sign the facility's new Admission Agreement that does not indicate "Respite Stay Only" multiple times but R1 always decline. Moreover, records review indicated that 30 Day Eviction Notice was provided to R1 on 10/28/2024 due to non-compliance in signing the permanent residency agreement. Furthermore, LPA Brown noted that the facility did not evict R1 as LPA Brown observed R1 still living at the facility during the facility visit on 01/29/2025.

Therefore, based on the evidence obtained during LPA Brown's investigation, there is insufficient evidence to prove Unlawful Eviction is UNSUBSTANTIATED at this time. Although the allegation of Unlawful Eviction 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 UNSUBSTANTIATED at this time.

An exit interview was conducted where this report (LIC9099), was discussed and provided to ED Andrea Perez.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 04/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2025
LIC9099 (FAS) - (06/04)
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