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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 107208818
Report Date: 04/15/2024
Date Signed: 04/15/2024 11:09:30 AM

Substantiated


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
04/10/2024 and conducted by Evaluator Katie Brown
PUBLIC
COMPLAINT CONTROL NUMBER: 24-AS-20240410115821
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: 5DATE:
04/15/2024
UNANNOUNCEDTIME BEGAN:
08:55 AM
MET WITH:Lisa PuaTIME COMPLETED:
11:15 AM
ALLEGATION(S):
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Resident left facility unassisted resulting in injury
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Katie Brown arrived at the facility unannounced to conduct the initial 10-Day visit. LPA met with and explained the reason for visit and elements of the allegation with Assistant Administrator (AD) Lisa Pua. LPA investigated the allegation and delivered complaint findings during the visit.
On 4/5/2024, Resident (R1), who has Dementia left the facility without staff being aware. While out of the facility, R1 sustained injury and was treated at the hospital. Based on interview and record review of R1's file, the preponderance of evidence standndard has been met, therefore the above allegations are found to be SUBSTANTIATED.

A deficiency is being cited in accordance with California Code of Regulations on the attached LIC 9099-D.
An immediate Civil Penalty is being assessed on the attached LIC421M.

An exit interview was conducted and Plan of Correction was developed. A copy of this report and Appeal Rights were discussed and left with AD, whose signature on this form confirms receipt of these documents.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Katie Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 04/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2024
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 24-AS-20240410115821
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/15/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/16/2024
Section Cited
HSC
1569.312(a)
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ยง1569.312 Basic services requirements
Every facility required to be licensed under this chapter shall provide at least the following basic services:
(a) Care and supervision as defined in Section 1569.2.
*This requirement was not met as evidenced by:
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AD has agreed to submit a written statement which will include revision of resident check out and AWOL procedures. Staff will be trained on revised procedures within 7 days. This statement will be emailed to CCL by POC date.
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Licensee did not ensure care and supervision was provided to R1. On 4/5/24, R1 left the facility alone without staff knowing. R1 sustained injury and required hospitailzation.
This poses an immediate health, safety or personal rights risk to persons in care.
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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.
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Katie Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 04/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2024
LIC9099 (FAS) - (06/04)
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