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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 115002791
Report Date: 11/12/2025
Date Signed: 11/12/2025 02:04:19 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/07/2025 and conducted by Evaluator Kerry Hiratsuka
COMPLAINT CONTROL NUMBER: 59-AS-20251107110410
FACILITY NAME:RIVERSIDE COUNTRY HOMEFACILITY NUMBER:
115002791
ADMINISTRATOR:LOEWEN, ROLANDFACILITY TYPE:
740
ADDRESS:8096 HIGHWAY 162TELEPHONE:
(530) 934-3686
CITY:GLENNSTATE: CAZIP CODE:
95943
CAPACITY:10CENSUS: 5DATE:
11/12/2025
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Roland LoewenTIME COMPLETED:
02:10 PM
ALLEGATION(S):
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Facility was refusing visitations
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Hiratsuka, conducted this unannounced complaint visit.

LPA inteviewed the staff on duty. The incident in question involved an Ombudsman, who has the authority to visit residents at any time unannounced, was refused entry by staff on duty. Today, LPA conducted interviews and found out the person working the day of the incident refused entry due to a miscommunication of identiy and the person working was protecting the residents. Administrator stated all staff have been informed about the ombudsman program since the incident.

Based on the information gathered through interviews, LPA was able to determine that the allegation is substantiated. Therefore, the Department finds the allegation to be Substantiated. A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

Please see 9099-D for the deficiency cited. Appeal rights left with administrator
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Kerry Hiratsuka
LICENSING EVALUATOR SIGNATURE:

DATE: 11/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/12/2025
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 59-AS-20251107110410
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: RIVERSIDE COUNTRY HOME
FACILITY NUMBER: 115002791
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/12/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/12/2025
Section Cited
CCR
87468.1(a)(11)
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Personal Rights of Residents in All Facilities. Residents in all residential care facilities for the elderly shall have all of the following personal rights: To have their visitors, including ombudspersons and advocacy representatives, permitted to visit privately during reasonable hours and without prior
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By 12/12/2025, the licensee shall submit a written plan of correction on how they shall ensure all staff know who the ombudsman are and what the ombudsman are allowed to do.
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notice, provided that the rights of other residents are not infringed upon.This requirement not met as evidence by a caregiver not allowing an ombudsman entry to the facility, which poses a potential health and safety risk to resident 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: Troy Ordonez
LICENSING EVALUATOR NAME: Kerry Hiratsuka
LICENSING EVALUATOR SIGNATURE:

DATE: 11/12/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/12/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2