361881134-9-27-2023-56-AS-NBRN-CWJW5B-20231012165849

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 361881134
Report Date: 09/27/2023
Date Signed: 09/27/2023 11:42:03 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 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
09/22/2023 and conducted by Evaluator Amber Coleman

PUBLIC

COMPLAINT CONTROL NUMBER: 56-AS-20230922134949

FACILITY NAME:	ALLARA SENIOR LIVING		FACILITY NUMBER:	361881134
ADMINISTRATOR:	HEFNER, LEEANN		FACILITY TYPE:	740
ADDRESS:	9417 19TH STREET		TELEPHONE:	(909) 736-1900
CITY:	RANCHO CUCAMONGA	STATE: CA	ZIP CODE:	91701
CAPACITY:	120	CENSUS: 20	DATE:	09/27/2023
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Helen Jaquez, Administrator		TIME COMPLETED:	11:45 AM

ALLEGATION(S):

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Staff did not provide adequate supervision resulting in resident sustaining bruising.

INVESTIGATION FINDINGS:

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Licensing Program Analyst, Amber Coleman, (LPA) arrived at the Allara Senior Living Facility unannounced to conduct a complaint investigation into the allegation listed above. LPA met with Administrator, Helen Jaquez. LPA introduced self and stated purpose of the visit. Administrator escorted LPA to the Memory Care Unit to meet with staff and the resident.

It is alleged that facility staff did not provide adequate supervision resulting in resident sustaining injury.
LPA walked through facility, interviewed staff, and collected pertinent documents. LPA observed that R1 resides inside of the facility's memory care unit. Staff interviews revealed that the facility uses staffing agencies to fill vacancies due to vacations or when staff cannot make their shift. This could be due to illness, family emergency, etc. The facility also care for residents who are on service with hospice services; which means hospice staff visit residents at the facility to provide care/services. The facility conducted an investigation and found that a staff member of a third party agency was the last to work with

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Amber Coleman	TELEPHONE: 951-248-0338
LICENSING EVALUATOR SIGNATURE:	DATE: 09/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2023

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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Control Number 56-AS-20230922134949

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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

FACILITY NAME: ALLARA SENIOR LIVING	FACILITY NUMBER: 361881134
	VISIT DATE: 09/27/2023

NARRATIVE

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R1. This third party staff member reports that there was no incident to report. The Hospice agency reports having no knowledge or observation of R1 having a fall. Facility staff report no knowledge or observation of R1 having a fall. Interviews with caregivers who work with R1 report, it is a behavior of R1 to make attempts to get out of bed unsupervised and often needs to be re-directed.

Based on information above, LPA has received conflicting information; these allegations are 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 Gabriel Salazar, Resident Care Director, where this report was reviewed, discussed then provided.

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Amber Coleman	TELEPHONE: 951-248-0338
LICENSING EVALUATOR SIGNATURE:	DATE: 09/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2023

LIC9099 (FAS) - (06/04)

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