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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336426511
Report Date: 06/22/2021
Date Signed: 06/22/2021 11:47:23 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:AVISTA SENIOR LIVING MAGNOLIAFACILITY NUMBER:
336426511
ADMINISTRATOR:SARAH DEVOREFACILITY TYPE:
740
ADDRESS:737 MAGNOLIA AVETELEPHONE:
(951) 737-1600
CITY:CORONASTATE: CAZIP CODE:
92879
CAPACITY:180CENSUS: 111DATE:
06/22/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Blasia Lee-Lole, Health and Wellness DirectorTIME COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Amy Goldenberg Conducted an unannounced case management visit to conclude this agency's inquiry into the questionable death of a resident (R1). LPA met with Health and Wellness Director Blasia Lee-Lole to disclose this agency's findings.

The department investigation included file review, interviews with staff/residents/witnesses, and collecting pertinent records.

Allegation #1: Interviews and record reviews conducted by the department revealed that R1 fell from the third story balcony between the dates of May 11 and May 13, 2020. R1 suffered an accidental fall from the third story balcony onto the planter area in the center of the facility courtyard. The fall was witnessed by a resident sitting at the balcony across from R1’s balcony. The Coroner determined the death as an accident and cause of death was multiple blunt impact injuries. The evidence that was collected showed that R1’s accident was not a result of lack of care.

Based on the investigation the allegation questionable death due to lack of care is unfounded. The department has found that the complaint was UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without reasonable basis.

This report was reviewed with and a copy was provided to the facility representative.
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 248-0339
LICENSING EVALUATOR NAME: Amy GoldenbergTELEPHONE: (951) 248-0351
LICENSING EVALUATOR SIGNATURE:

DATE: 06/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
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