361880660-5-11-2023-18-AS-JESL-CSE7YP-20230601220503

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 361880660
Report Date: 05/11/2023
Date Signed: 05/11/2023 02:19:22 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/07/2020 and conducted by Evaluator Javina George

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20200707151257

FACILITY NAME:	RIALTO ASSISTED LIVING		FACILITY NUMBER:	361880660
ADMINISTRATOR:	KYONG SUK LEE		FACILITY TYPE:	740
ADDRESS:	1441 S RIVERSIDE AVE		TELEPHONE:	(909) 877-2340
CITY:	RIALTO	STATE: CA	ZIP CODE:	92376
CAPACITY:	94	CENSUS: 50	DATE:	05/11/2023
		UNANNOUNCED	TIME BEGAN:	01:40 PM
MET WITH:	Tae Kim, Administrator		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Facility has bug infestation.

INVESTIGATION FINDINGS:

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Licensing Porgram Analyst (LPA) Javina George made an unannounced visit to the facility to deliver findings for the allegation listed above. LPA met with Tae Kim, Administrator and explained the purpose of the visit. The allegation listed above were investigated. The investigation consisted of observation, interviews and record review.

Regarding the allegation facility has a bug infestation. It was reported that in July 2020, that the facility had a bug infestation particulary in rooms # 33 and 35. Per interviews conducted with mutltiple staff and residents confrimed that there was in fact a bed bug problem/infestation at the facility. Information from an interview revealed that had been at minimum of seven bed bugs observed/found on the bed inside room #33. A bed bug was reported to have been found inside of the mop buckets, which were to believe to have gotten in there after cleaning one of the rooms noted to have bed bugs inside. Additionally, an interview conducted with the previous Administrator Kyong Suk Lee "Clara", whom admitted that the facility had a bed bug problem which resulted in the baseboards having to be removed, and the exterminator having to come out to treat the room. ****Continued on 9099C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Joel Esquivel	TELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javina George	TELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:	DATE: 05/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/11/2023

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 5

Control Number 18-AS-20200707151257

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

FACILITY NAME: RIALTO ASSISTED LIVING	FACILITY NUMBER: 361880660
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/11/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 05/12/2023 Section Cited CCR 87303(a)	1 2 3 4 5 6 7	Maintenance and Operation: (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	There is POC due as the facility there is no longer a bed bug infestation. A copy of treatment invoices were provided to LPA.
	8 9 10 11 12 13 14	Based on interviews and observations, the Licensee failed to ensure that at least 1 out of 48 rooms were kept clean and sanitary at all times. This is poses an immediate health risk to residents.	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: Joel Esquivel	TELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javina George	TELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:	DATE: 05/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/11/2023

LIC9099 (FAS) - (06/04)

Page: 5 of 5

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/07/2020 and conducted by Evaluator Javina George

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20200707151257

FACILITY NAME:	RIALTO ASSISTED LIVING		FACILITY NUMBER:	361880660
ADMINISTRATOR:	KYONG SUK LEE		FACILITY TYPE:	740
ADDRESS:	1441 S RIVERSIDE AVE		TELEPHONE:	(909) 877-2340
CITY:	RIALTO	STATE: CA	ZIP CODE:	92376
CAPACITY:	94	CENSUS: 50	DATE:	05/11/2023
		UNANNOUNCED	TIME BEGAN:	01:40 PM
MET WITH:	Tae Kim, Administrator		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Resident was not provided with reasonable accommodation.

INVESTIGATION FINDINGS:

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Licensing Porgram Analyst (LPA) Javina George made an unannounced visit to the facility to deliver findings for the allegation listed above. LPA met with Tae Kim, Administrator and explained the purpose of the visit. The allegation was investigated. The investigation consisted of observation, interviews and record review.

Regarding the allegation resident's was not provided with reasonable accommodation.
It was reported that on or around the month of June 2020 Resident #1 (R1) needed to be transported to the bank as they had a combination of both cash and a check that they were going to use to pay their rent, and only had the check in their account. R1 stated that they made a request to the Licensee to return the check, to them, so that they would not incur any additional charges. However the Licensee stated that R1s request could not be granted as they had already depositied the check at the bank. Per interviews conducted with office staff, R1 is not someone that usually needs tranportation but could utilize if needed and that the facility has an account with a certain bank and that once the check was deposited it could not be returned.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Joel Esquivel	TELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javina George	TELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:	DATE: 05/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/11/2023

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 5

Control Number 18-AS-20200707151257

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

FACILITY NAME: RIALTO ASSISTED LIVING	FACILITY NUMBER: 361880660
	VISIT DATE: 05/11/2023

NARRATIVE

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LPA was unable to obtain supporting evidence to corroborate what was alleged with the resident not being provided with a reasonable accommodation. Based on observation, interviews and record review the allegation is UNSUBSTANTIATED. A finding of UNSUBSTANTIATED means that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur.

An exit interview was conducted, and a copy of this report was reviewed and provided to Tae Kim, Administrator.

SUPERVISOR'S NAME: Joel Esquivel	TELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javina George	TELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:	DATE: 05/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/11/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 5

Control Number 18-AS-20200707151257

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

FACILITY NAME: RIALTO ASSISTED LIVING	FACILITY NUMBER: 361880660
	VISIT DATE: 05/11/2023

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32	Based on interviews the allegation of facility has bug infestation is SUBSTANTIATED. A substantiated finding means that the preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED. An exit interview was conducted and a copy of this report, 9099D, and appeal rights were provided to Tae Kim, Administrator.

SUPERVISOR'S NAME: Joel Esquivel	TELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javina George	TELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:	DATE: 05/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/11/2023

LIC9099 (FAS) - (06/04)

Page: 4 of 5