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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 107208818
Report Date: 01/06/2022
Date Signed: 01/06/2022 01:51:39 PM

Unsubstantiated


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
10/18/2021 and conducted by Evaluator Katie Brown
PUBLIC
COMPLAINT CONTROL NUMBER: 24-AS-20211018085621
FACILITY NAME:RIVERSIDE SENIOR CAREHOMEFACILITY NUMBER:
107208818
ADMINISTRATOR:BAUTISTA, ARLENEFACILITY TYPE:
740
ADDRESS:7435 N RIVERSIDE DRIVETELEPHONE:
(559) 412-8684
CITY:FRESNOSTATE: CAZIP CODE:
93722
CAPACITY:6CENSUS: DATE:
01/06/2022
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:TIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Staff is not properly assisting with administration of medications.
Staff is not caring for the resident.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Katie Brown arrived at the facility unannounced to conduct a subsequent complaint visit and deliver findings. The purpose of the visit and elements of the allegations were reviewed with Assistant Administrator, Lisa Pua.

The Department investigated the allegation: Staff is not properly assisting with administration of medications. Based on interviews conducted, text message and records review of the facility Medication Administration Record, Medication Assistance Procedure and Centrally Stored Medication Logs the allegation is unsubstantiated. 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. Therefore, the allegation is UNSUBSTANTIATED

See 9099-C for continuation
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Katie Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 01/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/06/2022
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-20211018085621
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: RIVERSIDE SENIOR CAREHOME
FACILITY NUMBER: 107208818
VISIT DATE: 01/06/2022
NARRATIVE
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The Department investigated the allegation: Staff is not caring for the resident.
Based on interview of staff and family member as well as review of R1’s file including Pre-Admission forms, facility admission agreement, House Rules, Plan of Care and Physicians Report it was not discovered that the facility did not provide agreed upon services or care. 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. Therefore, the allegation is UNSUBSTANTIATED.
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Katie Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 01/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/06/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2