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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331881006
Report Date: 03/28/2025
Date Signed: 03/28/2025 10:09:30 AM

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
02/02/2024 and conducted by Evaluator Janira Arreola
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20240202140052
FACILITY NAME:CONCORD ESTATES ASSISTED LIVINGFACILITY NUMBER:
331881006
ADMINISTRATOR:RAMIREZ, HEATHERFACILITY TYPE:
740
ADDRESS:31565 FLINTRIDGE WAYTELEPHONE:
(619) 251-8508
CITY:MURRIETASTATE: CAZIP CODE:
92563
CAPACITY:6CENSUS: 6DATE:
03/28/2025
UNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Staff, Sammi VasquezTIME COMPLETED:
10:15 AM
ALLEGATION(S):
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9
Staff did not provide care that met resident's needs
INVESTIGATION FINDINGS:
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13
Licensing Program Analyst (LPA) Janira Arreola conducted an unannounced visit to the facility to deliver the finding of the above allegation. LPA met with Staff, Sammi Vasquez, and the licensee Heather Ramirez over the phone who was informed of the purpose of the visit. LPA conducted interviews and records review.

It was alleged “Staff did not provide care that met resident's needs”. It was alleged staff did not get Resident #1 (R1) out of bed even when the resident requested it. It was alleged R1 was given a Hoyer lift by their medical provider, however this lift was never used by staff.

Interview with R1 was unable to be conducted as R1 has since passed away. Interview with (1) resident who resided at the home with R1 revealed they did not recall R1.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE:

DATE: 03/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2025
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 4
Control Number 18-AS-20240202140052
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: CONCORD ESTATES ASSISTED LIVING
FACILITY NUMBER: 331881006
VISIT DATE: 03/28/2025
NARRATIVE
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LPA conducted (2) staff interviews with staff who cared for R1. (2) of (2) staff revealed R1 was bedridden and unable to turn or reposition themselves in bed, and was turned every (2) hours. They revealed staff made attempts to get R1 out of bed but R1 was unable to tolerate it. (1) of (2) staff revealed a Hoyer lift was not used on R1 as R1 would yell out in pain due to a sore on their body.

Admission agreement and Hospice visit notes for R1 revealed R1 resided at the facility from 11/21/2022 to 12/24/2022. R1’s Hospice Care Plan from 11/21/2022 revealed R1 had a pressure injury on their bottom and was bedbound. Hospice equipment list revealed a Hoyer lift was ordered 10/31/2022, prior to R1 being placed at the facility when they were deemed non-ambulatory.

The facility’s internal “Two-hour Turn Log to Prevent Skin Breakdown” was documented every (2) hours for the resident during R1 stay at the facility.

Therefore, the allegation that R1 was not provided with the opportunity to be out of bed is unsubstantiated at this time. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. An exit interview was conducted, and a copy of this report was provided.

SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE:

DATE: 03/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 4
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
02/02/2024 and conducted by Evaluator Janira Arreola
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20240202140052

FACILITY NAME:CONCORD ESTATES ASSISTED LIVINGFACILITY NUMBER:
331881006
ADMINISTRATOR:RAMIREZ, HEATHERFACILITY TYPE:
740
ADDRESS:31565 FLINTRIDGE WAYTELEPHONE:
(619) 251-8508
CITY:MURRIETASTATE: CAZIP CODE:
92563
CAPACITY:6CENSUS: 6DATE:
03/28/2025
UNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Staff, Sammi VasquezTIME COMPLETED:
10:15 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not administer resident's medications as prescribed
Staff do not follow physician's order
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Janira Arreola conducted an unannounced visit to the facility to deliver findings for the above allegations. LPA met with Staff, Sammi Vasquez, and Licensee Heather Ramirez over the phone who was informed of the purpose of the visit. LPA conducted interviews and records review.

It was alleged “Staff did not administer resident's medications as prescribed”, regarding R1’s medication patch for Medication #1 (M1) that were incorrectly used. It was alleged there were (2) medication patches placed on R1 when they were prescribed (1) patch at a time. R1 was unable to be interviewed as R1 has since passed away.
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE:

DATE: 03/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 18-AS-20240202140052
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: CONCORD ESTATES ASSISTED LIVING
FACILITY NUMBER: 331881006
VISIT DATE: 03/28/2025
NARRATIVE
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Staff interview revealed R1 arrived at the facility with (2) medication patches on their body from their previous placement. It was revealed R1’s legal representative and a representative from R1’s hospice agency were also present for the incident. Interview with R1’s legal representative confirmed they witnessed R1 arrive to the facility with (2) medication patches on their body.

R1’s medication’s list revealed one medication patch for M1 was prescribed every 72 hours. Hospice visit notes for R1 revealed they resided at the facility from 11/21/2022 to 12/24/2022. The visit notes did not reveal any medication errors for R1’s patch. Therefore, the allegation that staff did not administer R1’s medication patches as prescribed is unfounded at this time.

It was alleged “Staff do not follow physician's order”. It was alleged R1’s speech pathologist ordered to not thicken R1’s liquids and that facility staff did not comply. Additional information for the speech pathologist was not available and review of R1’s hospice care plan did not reveal an assigned speech pathologist.

Interview with R1 was unable to be conducted as R1 has since passed away. LPA conducted (2) interviews with staff who cared for R1. (1) of (2) staff did not recall a speech pathologist being assigned to R1, and they recalled having physician’s orders to thicken R1 liquids as R1 had difficulty swallowing.

Medications list for R1 revealed fluid thickener was ordered by R1’s physician and started on 10/5/2022. Instructions on the medication list stated to thicken liquids to a nectar thick consistency. Therefore, the allegation that staff were not following R1’s physician orders is unfounded.

This agency has investigated the complaints and have found that the complaints are unfounded, meaning that the allegations were false, could not have happened and/or is without a reasonable basis. An exit interview was conducted, and a copy of this report was provided.

SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE:

DATE: 03/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 4