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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 547200264
Report Date: 07/29/2021
Date Signed: 07/29/2021 12:20:20 PM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/11/2021 and conducted by Evaluator Melinda Medina
PUBLIC
COMPLAINT CONTROL NUMBER: 24-AS-20210511102541
FACILITY NAME:RIVERSEDGE ELDERCAREFACILITY NUMBER:
547200264
ADMINISTRATOR:PRESTAGE, MARY ELLENFACILITY TYPE:
740
ADDRESS:285 SOUTH WESTWOODTELEPHONE:
(559) 788-0611
CITY:PORTERVILLESTATE: CAZIP CODE:
93257
CAPACITY:6CENSUS: 0DATE:
07/29/2021
UNANNOUNCEDTIME BEGAN:
10:37 AM
MET WITH:Mary Ellen PrestageTIME COMPLETED:
11:08 AM
ALLEGATION(S):
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Staff restrained resident in wheelchair.
INVESTIGATION FINDINGS:
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Licensing Program Manager (LPM) M. Hoffmann and Licensing Program Analyst (LPA) M. Medina conducted a subsequent complaint visit on this date. LPA met with Licensee, Mary Ellen Prestage and stated purpose of visit.

LPA Medina conducted subsequent facility tour on this date. Based on the information gathered during the complaint investigation, interviews conducted and photos received by Department. LPA observed photos of R1 sitting in wheelchair with arms positioned behind handles on the back of wheelchair.

This complaint allegation is SUBSTANTIATED.

Deficiency issued on attached 9099D.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 650-7914
LICENSING EVALUATOR NAME: Melinda MedinaTELEPHONE: (559) 410-5914
LICENSING EVALUATOR SIGNATURE:

DATE: 07/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2021
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 2
Control Number 24-AS-20210511102541
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: RIVERSEDGE ELDERCARE
FACILITY NUMBER: 547200264
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/29/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/29/2021
Section Cited
CCR
87468.1(a)(2)
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Personal Rights of Risidents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations,
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Licensee issued notices of closures effective 8/5/2021. At this time no evidence of residents residing in facility.

CLEARED AT TIME OF VISIT.
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furnishings and equipment.
**This was not met as evidenced by Department received pictures of R1 sitting in wheelchair with arms positioned behind handles on the back of wheelchair.


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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 650-7914
LICENSING EVALUATOR NAME: Melinda MedinaTELEPHONE: (559) 410-5914
LICENSING EVALUATOR SIGNATURE:

DATE: 07/29/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 2