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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 336426772
Report Date: 07/26/2021
Date Signed: 07/26/2021 12:14:25 PM



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
RIVERSIDE, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/04/2019 and conducted by Evaluator Shaunte Henry
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20191104104931
FACILITY NAME:AILIDA RETIREMENT HOMEFACILITY NUMBER:
336426772
ADMINISTRATOR:ANNALISA OLIVAN-BLANCAFLORFACILITY TYPE:
740
ADDRESS:38124 AUGUSTA DRIVETELEPHONE:
(951) 696-2482
CITY:MURRIETASTATE: CAZIP CODE:
92563
CAPACITY:6CENSUS: 4DATE:
07/26/2021
UNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Anna Flori, AdministratorTIME COMPLETED:
12:25 PM
ALLEGATION(S):
1
2
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9
1)Facility staff failed to assist resident with transfer.
2)Resident left without clothing for an extended period of time.
INVESTIGATION FINDINGS:
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On 7/26/21 Licensing Program Analysts (LPA)s Shaunte Henry and Anna Bueno delivered the findings to the above allegations. The LPAs met with Anna Flori. The Department investigated the above allegations. The investigation, which consisted of interviews and document review, revealed the following:

ALLEGATION #1: "Facility staff failed to assist resident with transfer". Staff 1 (S1) and Staff 2 (S2) reported experiencing difficulty while transfering Resident 1 (R1). Both staff denied failing to assist R1 with transferring. R1 was not interviewed due to being non-verbal. The Department was not able to gather sufficient evidence to support the allegation did or did not occur, therefore the allegation is unsubstantiated at this time.

ALLEGATION #2 : "Resident left without clothing for an extended period of time".
S1 and S2 reported that R1 resisted assistance with dressing after bathing. Staff denied leaving R1 without clothing for an extended period of time. S1 indicated the Home Health Aid was nearby, however R1 was covered. ***continued on 9099C***
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Shaunte HenryTELEPHONE: (951) 217-0236
LICENSING EVALUATOR SIGNATURE:

DATE: 07/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2021
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 2
Control Number 18-AS-20191104104931
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
RIVERSIDE, CA 92507
FACILITY NAME: AILIDA RETIREMENT HOME
FACILITY NUMBER: 336426772
VISIT DATE: 07/26/2021
NARRATIVE
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***Continued from 9099***

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 both allegations are UNSUBSTANTIATED at this time. An exit interview was conducted where this report was discussed with and provided to the administrator.
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Shaunte HenryTELEPHONE: (951) 217-0236
LICENSING EVALUATOR SIGNATURE:

DATE: 07/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 2