374604135-10-26-2023-18-AS-RSTS-CYPUSU-20231220145053

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374604135
Report Date: 10/26/2023
Date Signed: 10/26/2023 04:21:06 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: 37	DATE:	10/26/2023
		UNANNOUNCED	TIME BEGAN:	01:08 PM
MET WITH:	Levina Dubose - Executive Director		TIME COMPLETED:	04:27 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Resident's rooms are not kept at a comfortable temperature
Facility is not adhering to resident's dietary needs
Facility is not giving resident's their mail in a timely manner

INVESTIGATION FINDINGS:

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

Licensing Program Analyst (LPA) Sara Martinez conducted an unannounced visit to the facility to initiate an investigation regarding the allegations listed above. LPA was granted entry and met with Executive Director Levina Dubose who was informed of the purpose for this visit. LPA toured the facility, reviewed records, conducted interviews, and took copies of pertinent information.

Regarding the allegation "Resident's rooms are not kept at a comfortable temperature", LPA conducted interviews with staff, residents, and made observations during the tour of the facility. LPA noted that the facility is a two-story building and the temperatures on both floors were set at 74 degrees per the thermostat settings located and displayed throughout the facility. After interviews with staff, residents, and noting the observations of the area, LPA found residents were comfortable in their rooms. Thus, LPA determined that the allegation was Unsubstantiated.
(CONTINUED LIC 9099-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: 10/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 1 of 3

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: 10/26/2023

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Regarding allegation "Facility is not adhering to resident's dietary needs" Resident One (R1) stated the facility serves food that is salty and goes against R1's dietary needs. It was alleged that R1 is on a required low sodium diet, but the facility does not abide by it. R1 allegedly gets the same food as everyone else. LPA conducted interviews with staff, residents, and conducted a record review for R1 that does not corroborate R1's claimed low sodium dietary needs. R1's Physician report and Physician Orders show R1 does not have any special dietary needs and is on a regular diet. Interviews with staff and residents revealed that the facility provides alternative options for the residents to choose from. Thus, this allegation is Unsubstantiated.

Regarding the allegation "Facility is not giving resident's their mail in a timely manner" LPA conducted interviews with staff and residents and found the claim did not corroborate with LPA's findings. Through interviews conducted with residents and staff, LPA found that mail is distributed daily and that residents do not have issues receiving their mail in a timely manner. Thus, this allegation was UNSUBSTANTIATED.

A finding of UNSUBSTANTIATED means that 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 where a copy of this report was discussed with and 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: 10/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 3