336426511-5-28-2024-56-AS-EMAN-D7PMWW-20240731095901

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 336426511
Report Date: 05/28/2024
Date Signed: 05/28/2024 02:27:59 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
05/22/2024 and conducted by Evaluator Mary Rico

PUBLIC

COMPLAINT CONTROL NUMBER: 56-AS-20240522135208

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: 106	DATE:	05/28/2024
		UNANNOUNCED	TIME BEGAN:	12:15 AM
MET WITH:	Administrator Kellie Ann Smith and Sales Director Chad Ormsby		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Staff intimidated resident in care
Resident in care is not provided a reasonable level of personal privacy

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Mary Rico conducted an unannounced visit to investigate and deliver findings on the allegations listed above. LPA met with Administrator Kellie Ann Smith and explained the purpose of the visit. The investigation consisted of staff interviews, resident interviews, document reviews, and facility tour.

For the allegation, Staff intimidated resident in care.

LPA Rico conducted 8 resident interviews. 8 out of the 8 residents stated the have not been intimidated by staff members while in care.

LPA Rico conducted 6 staff interviews. 6 out of the 6 staff informed LPA they have not intimidated a resident while in care. 3 out of the 6 staff stated they are not aware if other staff members have intimidated their residents.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 248-0337
LICENSING EVALUATOR NAME: Mary Rico	TELEPHONE: (951) 248-0293
LICENSING EVALUATOR SIGNATURE:	DATE: 05/28/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2024

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-20240522135208

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: 05/28/2024

NARRATIVE

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For the allegation, Resident in care is not provided a reasonable level of personal privacy.

During resident interviews, 8 out of the 8 residents informed LPA personal privacy is being provide. 5 out of the 8 residents also stated that staff members knock before entering their rooms and and will not enter without their permission.

During staff interviews. 6 out of the 6 staff informed LPA they provide privacy to all their residents. 3 out of the 6 staff informed LPA they will not enter a resident room unless they are authorized. 2 out of the 6 staff informed LPA R1 has signs outside their bedroom to not enter. In addition, 5 out of the 6 stated that R1 is forgetful when they drink and will accuse staff members entering their room without permission.

Based on the evidence found during the investigation, the two (2) allegations listed above are deemed UNSUBSTANTIATED. A finding that the complaints are UNSUBSTANTIATED means although the allegation may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations 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 was discussed and provided to Sales Director Chad Ormsby along with a copy of the appeal rights.

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 248-0337
LICENSING EVALUATOR NAME: Mary Rico	TELEPHONE: (951) 248-0293
LICENSING EVALUATOR SIGNATURE:	DATE: 05/28/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2024

LIC9099 (FAS) - (06/04)

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