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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 336426772
Report Date: 06/12/2020
Date Signed: 06/17/2020 08:18:11 AM



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
11/07/2019 and conducted by Evaluator Yolanda Bejarano
COMPLAINT CONTROL NUMBER: 18-AS-20191107101908
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: 5DATE:
06/12/2020
ANNOUNCEDTIME BEGAN:
11:10 AM
MET WITH:Annalisa Olivan-BlancaflorTIME COMPLETED:
11:30 AM
ALLEGATION(S):
1
2
3
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7
8
9
Staff failed to properly assist the resident and caused an injury to the resident

INVESTIGATION FINDINGS:
1
2
3
4
5
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7
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9
10
11
12
13
Licensing Program Analyst (LPA) Yolanda Bejarano contacted the facility via telephone to deliver findings via telephone due to COVID-19, LPA identified herself.

Regarding the allegation of "staff failed to properly assist the resident and caused an injury to the resident". LPA conducted staff interviews and requested R1's file for review including hospice notes, copies were provided. LPA was unable to interview R1 due to passing away on 11/7/2019. Documentation gathered indicated redness on the right hip. RN pointed out the red area to administrator Anna, RN explained to be gentle with diaper change and open areas, no training was provided. S1 denied any injury & neglect to R1.
Based on the information gathered LPA was unable to find sufficient evidence to corroborate or dismiss the allegation, therefore allegations is UNSUBSTANTIATED. The complaint is UNSUBSTANTIATED means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the allegation(s) occurred.

Exit interview conducted and copy provided to administrator.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Yolanda BejaranoTELEPHONE: (951) 2176360
LICENSING EVALUATOR SIGNATURE:

DATE: 06/12/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/12/2020
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
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
11/07/2019 and conducted by Evaluator Yolanda Bejarano
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20191107101908

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: 5DATE:
06/12/2020
UNANNOUNCEDTIME BEGAN:
11:10 AM
MET WITH:AnnaLisa Olivan-Blancaflor TIME COMPLETED:
11:30 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff are failing to abide by the Hospice care plan.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
LPA Bejarano discussed the findings via telephone due to Covid19.

Regarding the allegation of "Staff are failing to abide by the Hospice care plan" LPA Bejarano interviewed staff regarding hospice supplies missing for the residents on hospice. Administrator stated that all hospice supplies are kept in one location availalbe to staff. LPA toured the facility and confirmed that supplies are kept in one area for easy access.

Therefore based on the interviews and tour of the supply room the allegations is UNFOUNDED. This agency has investigated the complaint alleging "staff are failing to abide by the Hospice care plan. We have found that the complaint was UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. We have therefore dismissed the complaint.

Exit interview conducted and copy of report provided to administrator
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Yolanda BejaranoTELEPHONE: (951) 2176360
LICENSING EVALUATOR SIGNATURE:

DATE: 06/12/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/12/2020
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 2