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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 336426511
Report Date: 06/02/2022
Date Signed: 06/02/2022 11:00:35 AM

Substantiated


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
05/24/2022 and conducted by Evaluator Jennifer Semin
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20220524123756
FACILITY NAME:AVISTA SENIOR LIVING MAGNOLIAFACILITY NUMBER:
336426511
ADMINISTRATOR:MONIQUE DEL JUNCOFACILITY TYPE:
740
ADDRESS:737 MAGNOLIA AVETELEPHONE:
(951) 737-1600
CITY:CORONASTATE: CAZIP CODE:
92879
CAPACITY:180CENSUS: 117DATE:
06/02/2022
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Blasia Lee-Lole and Alexis BrownTIME COMPLETED:
11:15 AM
ALLEGATION(S):
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Facility staff did not safeguard residents medication
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Jennifer Semin conducted an unannounced visit to initiate and deliver the findings for the above complaint allegation. LPA met with Administrator, Blasia Lee-Lole and Health Services Director, Alexis Brown.
The investigation consisted of relevant party interviews. In regard to the allegation, Facility staff did not safeguard resident’s medication, interviews with staff revealed resident medication for residents not on medication management is dropped off by the pharmacy and kept at the front desk for residents to pick up. Medication was not delivered to the residents and staff misplaced the medication. According to staff, the medication was found about a week later in the medication room, but it is unclear how it got there. Resident 1 reordered medications but did receive their misplaced medication about one week later.
Based on interview, 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 Ms. Brown.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Jennifer SeminTELEPHONE: (951) 473-7024
LICENSING EVALUATOR SIGNATURE:

DATE: 06/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2022
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-20220524123756
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: 06/02/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/03/2022
Section Cited
CCR
87456(h)(2)
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Medication & Dental Care: Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.
This regulation was not met as evidence by, Staff did not take delivered medication directly to the resident or the medication room upon
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Licensee shall read the regulation in its entrirety, submit a statement of uinderstanding, create protocols to ensure medication remains locked up at all times and train staff on this regualtion and new protocols and submit the POC to CCL by the POC due date of 6/3/2022.
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delivery and medication was misplaced. This poses an immediate health and safety risk to resdients in care.
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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 MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Jennifer SeminTELEPHONE: (951) 473-7024
LICENSING EVALUATOR SIGNATURE:

DATE: 06/02/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2022
LIC9099 (FAS) - (06/04)
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