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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361880660
Report Date: 10/10/2023
Date Signed: 10/10/2023 11:23:15 AM


Document Has Been Signed on 10/10/2023 11:23 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507



FACILITY NAME:RIALTO ASSISTED LIVINGFACILITY NUMBER:
361880660
ADMINISTRATOR:KYONG SUK LEEFACILITY TYPE:
740
ADDRESS:1441 S RIVERSIDE AVETELEPHONE:
(909) 877-2340
CITY:RIALTOSTATE: CAZIP CODE:
92376
CAPACITY:94CENSUS: 54DATE:
10/10/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:05 AM
MET WITH:Bernie Escueta, NurseTIME COMPLETED:
12:15 PM
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Licensing Program Analyst, Amber Coleman, (LPA) arrived at the Rialto Assisted Living facility unannounced to conduct a Case Management Visit. The Case Management visit is being conducted in response to a Special/Unusual Incident Report, (SIR) submitted to the agency on 9/27/23. LPA met with caregiver, Bernie Escueta. LPA introduced self and stated purpose of the visit.

The SIR documents that on 9/25/23, Dietary Staff, Martha Garcia, (S1) observed R1 and R2 engaged in a physical altercation with one another in the Dining Room. S1 called for assistance and physically separated the residents from one another. The Paramedics were contacted to transport to the Hospital for medical evaluations.

Inquiry into this incident included conducting a facility tour to assess for any Health and Safety concerns. LPA observed no imminent health and safety concerns at the time of visit. LPA was unable to interview R1 because they have relocated to another facility. Staff informed LPA R2 was out for the day with family. LPA was able to interview staff and review the residents chart.

Based on the observations made during today’s visit, there were no deficiencies cited per Title 22, Division 6, of the California Code or Regulations. An exit interview to review this report was conducted and a copy of this report was provided to a facility representative.
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Amber ColemanTELEPHONE: 951-248-0338
LICENSING EVALUATOR SIGNATURE:
DATE: 10/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/10/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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