361880660-8-24-2023-18-AS-NBRN-CV2VGX-20230825162616

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 361880660
Report Date: 08/07/2023
Date Signed: 08/24/2023 01:29:05 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
12/08/2020 and conducted by Evaluator Anna Bueno

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20201208165511

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: 51	DATE:	08/07/2023
		UNANNOUNCED	TIME BEGAN:	01:22 PM
MET WITH:	Tae Kim - Administrator		TIME COMPLETED:	03:35 PM

ALLEGATION(S):

1
2
3
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5
6
7
8
9

Questionable Death

INVESTIGATION FINDINGS:

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

Licensing Program Analyst (LPA) Anna Bueno conducted a subsequent visit to the facility to continued the investigation of and deliver findings on the above allegation. LPA met with administrator Tae Kim who was informed of the purpose of today’s visit. The investigation consisted of witness and resident interviews and records review.

The allegation is Questionable Death. It was alleged that on 12/08/2020 Resident (R1) passed away. Interviews with witness and facility residents confirmed that R1 was in isolation due to a diagnosis. LPA reviewed Department records and found that this facility reported as required active cases diagnosed between November and December of 2020. LPA reviewed R1 records and found that R1 had preexisting conditions that made R1 a higher risk for severe illness. Based on interviews conducted, and documents reviewed the allegation is therefore unsubstantiated.

A finding of UNSUBSTANTIATED means, 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 with and a copy of this report was provided to Administrator Kim.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Anna Bueno	TELEPHONE: 951-204-4307
LICENSING EVALUATOR SIGNATURE:	DATE: 08/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2023

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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