374604135-11-21-2023-18-AS-RSTS-CYPUST-20231220145053

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374604135
Report Date: 11/21/2023
Date Signed: 11/21/2023 12:26:47 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 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
10/20/2023 and conducted by Evaluator Sara Martinez

COMPLAINT CONTROL NUMBER: 18-AS-20231020100749

FACILITY NAME:	SHADOWRIDGE		FACILITY NUMBER:	374604135
ADMINISTRATOR:	BEATRICE BRACAMONTE		FACILITY TYPE:	740
ADDRESS:	2354 WATSON WAY		TELEPHONE:	(760) 295-3888
CITY:	VISTA	STATE: CA	ZIP CODE:	92081
CAPACITY:	48	CENSUS: 36	DATE:	11/21/2023
		UNANNOUNCED	TIME BEGAN:	09:46 AM
MET WITH:	Levina Dubose - Executive Director		TIME COMPLETED:	12:37 PM

ALLEGATION(S):

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Staff leave medication accessible to facility residents
Resident took another resident's medication due to staff neglect
Facility staff is retaliating against a resident

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Sara Martinez conducted an unannounced visit to conclude and deliver findings to an investigation regarding the allegations listed above. LPA was granted entry and met with Executive Director Levina Dubose. LPA conducted a tour of the facility and conducted interviews and record review.

Regarding the allegations “staff leave medication accessible to facility residents” and “resident took another resident’s medication due to staff neglect” LPA conducted record reviews and interviews with staff and residents that does not corroborate with the allegations. Interviews with Staff One (S1) and Staff Two (S2) revealed that the medcart and medication room is always locked when not in use. S1 and S2 both stated when distributing medication they make sure the medication for the resident is correct and they watch the residents take the medication and swallow. S2 stated when they distribute medication in the dining room during meal time they hand the resident their cup and watch the resident swallow the medication and take the cup back from the resident to discard. Interviews with Resident One (R1) and Resident Two (R2) reveal they have never had any issues with receiving their medication or receiving the wrong medication. R1 stated they go to the medcart in the morning and the medtechs will hand them their medication. (CONTINUED LIC9099-C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Rikesha Stamps	TELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Sara Martinez	TELEPHONE: (951) 248-0314
LICENSING EVALUATOR SIGNATURE:	DATE: 11/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2023

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 18-AS-20231020100749

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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

FACILITY NAME: SHADOWRIDGE	FACILITY NUMBER: 374604135
	VISIT DATE: 11/21/2023

NARRATIVE

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R2 stated when they receive their medication in the dining room during their meal the medtech will ask their name and hand them a cup full of their medication. R2 stated the medtech will wait for the resident to take their medication.

During LPA’s initial visit and visit conducted today, LPA observed medtechs distributing medication to the residents at the medcart in front of the medication room. S1 asked the resident to identify themselves, distributed the medication in a cup, and watched the resident swallow the medication. On today's visit, S2 was delivering the afternoon medication to the residents in their room. Therefore based on observation, record review, and interviews the allegation has been deemed UNSUBSTANTIATED at this time.

Regarding the allegation “Facility staff is retaliating against a resident” it was alleged that Resident Three (R3) was being retaliated against by staff during mealtime by having their meal served to them last. Executive Director (ED) Dubose stated the servers rotate the serving order based on the table’s location in the dining room for every meal. For breakfast the table at the front of the dining room will receive their meal first and the table at the back of the dining room will receive their meal last. For lunch the table at the front of the dining room will receive their meal last and the table at the back of the dining room will be served first. ED Dubose stated the residents do not have assigned seats but the residents tend to always sit at the same table. Interviews with residents had corroborated with ED Dubose on the order the residents are served their meals. Therefore based on observation, record review, and interviews the allegation has been deemed UNSUBSTANTIATED at this time.

A finding that the complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation(s) occurred.

An exit interview was conducted where a copy of this report and LIC811 - Confidential Names List, was provided to Executive Director Levina Dubose.

SUPERVISOR'S NAME: Rikesha Stamps	TELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Sara Martinez	TELEPHONE: (951) 248-0314
LICENSING EVALUATOR SIGNATURE:	DATE: 11/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2023

LIC9099 (FAS) - (06/04)

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