374604135-12-20-2023-18-AS-RSTS-D2AQFW-20240209110834

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374604135
Report Date: 12/20/2023
Date Signed: 12/20/2023 03:00:35 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
12/14/2023 and conducted by Evaluator Sara Martinez

COMPLAINT CONTROL NUMBER: 18-AS-20231214092215

FACILITY NAME:	SHADOWRIDGE SENIOR LIVING		FACILITY NUMBER:	374604135
ADMINISTRATOR:	DUBOSE, LEVINA		FACILITY TYPE:	740
ADDRESS:	2354 WATSON WAY		TELEPHONE:	(760) 295-3888
CITY:	VISTA	STATE: CA	ZIP CODE:	92081
CAPACITY:	48	CENSUS: 38	DATE:	12/20/2023
		UNANNOUNCED	TIME BEGAN:	09:39 AM
MET WITH:	Levina Dubose - Executive Director		TIME COMPLETED:	03:07 PM

ALLEGATION(S):

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Staff did not ensure that residents medical device was replaced
Staff shows favoritism towards a resident in care
Staff does not maintain a comfortable temperature for a resident in care
Staff is not ensuring that resident receives their mail

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Sara Martinez conducted an unannounced visit to the facility to initiate the 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.

During today's visit, LPA toured the facility, conducted interviews with staff and residents, and collected pertinent documents related to Resident One (R1). Regarding the allegation “Staff did not ensure that resident’s medical device was replaced”, it was reported R1 had a broken catheter bag for approximately a month and the facility did not ensure the medical device was replaced. Interview and record review with Executive Director (ED) Levina Dubose revealed R1 receives foley supplies from R1’s home health services. LPA contacted R1’s home health services and confirmed they supply foley supplies for R1 and informed LPA a nurse delivered three catheter bags to the facility on 12/19/23. ED informed LPA R1’s catheter bag broke approximately a month ago and ED had purchased and replaced a new bag for R1. Interview with R1 corroborated with ED purchasing and replacing catheter bag for R1.

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: 12/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2023

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-20231214092215

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 SENIOR LIVING	FACILITY NUMBER: 374604135
	VISIT DATE: 12/20/2023

NARRATIVE

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R1 confirmed with LPA during interview R1 was aware their home health services provide their catheter bag. Therefore, based on information obtained from interviews and record review the allegation has been deemed UNSUBSTANTIATED at this time.

Regarding the allegation “Staff shows favoritism towards a resident in care”, it was reported R1 is treated differently than other residents by staff regarding housekeeping. R1 stated they want their bed made first but feels staff assist other residents before R1 due to staff and residents having the same ethnicity. Interviews conducted with residents and staff revealed no observable favoritism from staff toward certain residents. Interview with Resident Two (R2) revealed staff are “nice and attentive” and whenever assistance is requested staff always assist when they can. Staff One (S1) stated there is “definitely no favoritism” with the residents from staff and S1 treats all the residents with dignity and respect. S1 stated they clean the residents' room in the morning based off if their assigned resident needs assistance getting up from their bed, showered, and dressed. Interview with ED revealed housekeeping is based on residents’ schedule in the morning and if the resident needs assistance getting up. If the resident wakes up and showers early, the staff assigned to the resident can enter the resident’s room and clean. Therefore, based on information obtained from interviews the allegation has been deemed UNSUBSTANTIATED at this time.

Regarding the allegation “Staff does not maintain a comfortable temperature for a resident in care” it was reported the facility is cold for residents in care. LPA observed the thermostat on the upper-level and lower-level of the facility set at 73 degrees during the facility tour. Interview with residents revealed the facility is kept at a comfortable temperature. Interview with Resident Three (R3) revealed they had no complaints about the facility temperature and that the “temperature is comfortable and if they were cold they would inform staff”. Interview with ED revealed if resident informed staff they were cold, staff would provide resident with a blanket or jacket. Therefore, based on information obtained from interviews and observations the allegation has been deemed UNSUBSTANTIATED at this time.

SUPERVISOR'S NAME: Rikesha Stamps	TELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Sara Martinez	TELEPHONE: (951) 248-0314
LICENSING EVALUATOR SIGNATURE:	DATE: 12/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 18-AS-20231214092215

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 SENIOR LIVING	FACILITY NUMBER: 374604135
	VISIT DATE: 12/20/2023

NARRATIVE

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Regarding the allegation “Staff is not ensuring that resident receives their mail” it was reported R1 has not received their mail due to staff not retrieving R1’s mail. R1 stated they have been “waiting for a birthday card from their friend” and has not received it. R1’s birthday was at the end of November and stated the facility staff does not retrieve R1’s mail on a timely basis. Resident and staff interviews reveal residents are receiving their mail and have not had any issues in their mail being delayed. ED stated staff checks the mailbox everyday and delivers the mail to the residents. Therefore, based on information obtained from 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 and a copy of this report along with LIC 811- Confidential names, was reviewed 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: 12/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2023

LIC9099 (FAS) - (06/04)

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