366413139-9-8-2023-56-AS-NBRN-CY3VRH-20231130153957

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 366413139
Report Date: 09/08/2023
Date Signed: 09/08/2023 03:25:01 PM

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
09/05/2023 and conducted by Evaluator Amber Coleman

COMPLAINT CONTROL NUMBER: 56-AS-20230905141914

FACILITY NAME:	KALIA HOME		FACILITY NUMBER:	366413139
ADMINISTRATOR:	PENDING		FACILITY TYPE:	735
ADDRESS:	902 N. LINDEN AVE		TELEPHONE:	(909) 429-4418
CITY:	RIALTO	STATE: CA	ZIP CODE:	92376
CAPACITY:	4	CENSUS: 1	DATE:	09/08/2023
		UNANNOUNCED	TIME BEGAN:	01:25 PM
MET WITH:	Alyssa Munoz, Staff Member		TIME COMPLETED:	03:35 PM

ALLEGATION(S):

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Staff did not seek medical care for resident in a timely manner.
Staff mismanaged resident medication.

INVESTIGATION FINDINGS:

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Licensing Program Analyst, Amber Coleman arrived at the Kalia Home, Adult Residential Facility unannounced to initiate a complaint investigation into the allegations listed above. LPA met with Staff Member, Alyssa Munoz who contacted the Administrator, Fernando Mendoza and reviewed the elements of the allegations. During today's visit, LPA conducted staff interviews, reviewed and collected pertinent documents.

It is alleged that staff did not seek medical care for resident in a timely manner. Record reviews revealed that Resident #1, (R1) has a medical condition in which symptoms include seizures. Medical records revealed that the R1 has a history with the medical condition for which they are receiving adequate medical treatment for. Staff interviews revealed that R1's seizures are not unusual due to the medical condition. R1's doctor advised R1 be taken for medical treatment should the symptoms worsen. This action was completed when staff called 911 for R1. Administrator stated, he was contacted by the hospital staff at which time R1's medical information was provided to an intern at Arrowhead Medical Center. Furthermore, Medical staff report that the resident is being discharged today (9/8/23) with no concerns noted for the facility's care.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amber Coleman
LICENSING EVALUATOR SIGNATURE:	DATE: 09/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2023

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-20230905141914

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: KALIA HOME	FACILITY NUMBER: 366413139
	VISIT DATE: 09/08/2023

NARRATIVE

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It is alleged that staff mismanaged the resident's medications. LPA observed R1's Medical Administration Record, (MARS) which indicated R1 is taking all medications as prescribed. No notes or history indicated R1 refusing any medications. R1's daily notes / progress notes indicate R1 takes her medications. LPA did not observe any medication errors made in the last 60 days. Staff denied that R1 has any problems with medications.

Based on interviews and observations, 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 facility representative and a copy of this report was provided.

SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amber Coleman
LICENSING EVALUATOR SIGNATURE:	DATE: 09/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2023

LIC9099 (FAS) - (06/04)

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