336426511-10-2-2023-56-AS-EMAN-CWAVMC-20231004163317

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 336426511
Report Date: 10/02/2023
Date Signed: 10/02/2023 01:15:21 PM

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
09/25/2023 and conducted by Evaluator Ryan Gardner

PUBLIC

COMPLAINT CONTROL NUMBER: 56-AS-20230925094954

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: 118	DATE:	10/02/2023
		UNANNOUNCED	TIME BEGAN:	11:50 AM
MET WITH:	Blasia Lee-Lole- Administrator		TIME COMPLETED:	01:24 PM

ALLEGATION(S):

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Staff does not prevent residents from speaking inappropriately to each other.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Ryan Gardner made an unannounced visit to investigate and deliver findings for the allegation listed above. LPA stated the purpose of the visit and was granted entry and met with Administrator Blasia Lee-Lole. The investigation consisted of resident interviews, staff interviews, and document review.

For allegation, Staff does not prevent residents from speaking inappropriately to each other:

Interviews with residents and the staff revealed that on 9/22/2023 there was a verbal altercation between two (2) residents. When the incident occurred, the two (2) residents were outside of the facility with no witnesses present. The staff was made aware of the verbal altercation after the incident occurred. The staff completed an internal investigation and found that there were not enough facts to prove what was said to the residents. A document review of the internal investigation revealed that there were no witnesses to the verbal altercation.

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: 10/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2023

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-20230925094954

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: 10/02/2023

NARRATIVE

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The staff spoke to both of residents involved about being respectful to each other. A notice of lease violation will be issued to both residents involved. The staff at the facility have been instructed to notify management if they observe any additional issues between the two (2) residents. Adult Protective Services (APS) came to the facility on 9/29/2023 to investigate the incident. The facility was not provided information regarding the outcome of APS’s visit.

Overall, there was not enough evidence to collaborate the allegation listed above.

Based on evidence obtained during the investigation, the allegation listed above is deemed 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: 10/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2023

LIC9099 (FAS) - (06/04)

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