336426511-4-19-2022-56-AS-EMAN-CEPUBC-20220523152604

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 336426511
Report Date: 04/19/2022
Date Signed: 04/19/2022 04:01:41 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
04/18/2022 and conducted by Evaluator Jennifer Semin

PUBLIC

COMPLAINT CONTROL NUMBER: 56-AS-20220418113818

FACILITY NAME:	AVISTA SENIOR LIVING MAGNOLIA		FACILITY NUMBER:	336426511
ADMINISTRATOR:	MONIQUE DEL JUNCO		FACILITY TYPE:	740
ADDRESS:	737 MAGNOLIA AVE		TELEPHONE:	(951) 737-1600
CITY:	CORONA	STATE: CA	ZIP CODE:	92879
CAPACITY:	180	CENSUS: 115	DATE:	04/19/2022
		UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Alexis Brown and Blasia Lee-Lole		TIME COMPLETED:	04:15 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility is not meeting resident's dietary needs.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Jennifer Semin arrived to the facility unannounced to initiate a complaint investigation into the above complaint allegations and deliver the findings. LPA met with Administrator, Blasia Lee-Lole and Business Office Manager (BOM) Rona Sanchez
The investigation consisted of interviews and review of records. The allegation, Facility is not meeting resident's dietary needs. Staff stated that the kitchen can accommodate some special diets. Staff stated Resident 1 (R1) verbalized they needed a special diet but did not submit documentation from their physician to staff regarding a special diet. R1 stated they submitted documentation from their physician to the front desk. Resident 2-4 (R2-4) stated the kitchen accommodates for their special diet. Based upon interviews and information gathered, and although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED at this time.
An exit interview was conducted where this report was discussed and provided to the administrator..

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Jennifer Semin	TELEPHONE: (951) 473-7024
LICENSING EVALUATOR SIGNATURE:	DATE: 04/19/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/19/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 1 of 3

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
04/18/2022 and conducted by Evaluator Jennifer Semin

PUBLIC

COMPLAINT CONTROL NUMBER: 56-AS-20220418113818

FACILITY NAME:	AVISTA SENIOR LIVING MAGNOLIA		FACILITY NUMBER:	336426511
ADMINISTRATOR:	MONIQUE DEL JUNCO		FACILITY TYPE:	740
ADDRESS:	737 MAGNOLIA AVE		TELEPHONE:	(951) 737-1600
CITY:	CORONA	STATE: CA	ZIP CODE:	92879
CAPACITY:	180	CENSUS: 115	DATE:	04/19/2022
		UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Alexis Brownand Blasia Lee-Lole		TIME COMPLETED:	04:15 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility allowing resident's to utilize another resident's room without obtaining consent.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Jennifer Semin arrived to the facility unannounced to initiate a complaint investigation into the above complaint allegations and deliver the findings. LPA met with Administrator, Blasia Lee-Lole and Business Office Manager (BOM) Rona Sanchez.
The investigation consisted of interviews and review of records. The allegation, Facility allowing resident's to utilize another resident's room without obtaining consent. Staff stated a new staff member did take Resident 2 (R2) into Resident 1’s (R1) room by mistake when R1 was not present. Staff stated they got the room mixed up. R1 stated R2 was in their apartment without their permission. R2 was unable to corroborate or refute the allegation.
Based on interviews and documentation, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6 & Chapter 1) is being cited on the attached LIC9099D.
An exit interview was conducted where this report was discussed and provided to the BOM.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Jennifer Semin	TELEPHONE: (951) 473-7024
LICENSING EVALUATOR SIGNATURE:	DATE: 04/19/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/19/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 56-AS-20220418113818

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/19/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 04/13/2022 Section Cited CCR 87411(a)	1 2 3 4 5 6 7	Personnel Requirements - General Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs....This requirement was not met as evidence by, staff did not know the	1 2 3 4 5 6 7	Licensss shall read the regulation in it's entirety, submit a statement of understanding and conduct staff training this regulation and submit it to CCL by the POC due date of 4/20/2022.
	8 9 10 11 12 13 14	resident nor what room they were assigned to when escorting the resident to their room. This poses a health and safety risk to resdents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Jennifer Semin	TELEPHONE: (951) 473-7024
LICENSING EVALUATOR SIGNATURE:	DATE: 04/19/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/19/2022

LIC9099 (FAS) - (06/04)

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