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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331881421
Report Date: 05/21/2025
Date Signed: 05/21/2025 04:56:49 PM

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
08/06/2024 and conducted by Evaluator Abdoulaye Zerbo
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20240806084343
FACILITY NAME:SMITH ROAD ASSISTED LIVINGFACILITY NUMBER:
331881421
ADMINISTRATOR:LECITA, MA SATCHELFACILITY TYPE:
740
ADDRESS:753 SMITH ROADTELEPHONE:
(951) 927-8178
CITY:HEMETSTATE: CAZIP CODE:
92544
CAPACITY:12CENSUS: 11DATE:
05/21/2025
UNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Veronica JacksonTIME COMPLETED:
05:00 PM
ALLEGATION(S):
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Staff does not ensure residents personal care needs are being met
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Abdoulaye Zerbo conducted an unannounced subsequent visit for additional investigation into the allegation listed above. LPA Abdoulaye was greeted and granted entrance by staff Veronica Jackson. LPA Abdoulaye Zerbo identified himself and discussed the purpose of the visit.

It was alleged Staff does not ensure residents personal care needs are being met. Concerns were made regarding resident‘s (R1) overgrown toenails and facility not meeting R1’s dental care. LPA conducted interviews and information obtained revealed R1’s insurance coverage did not carry dental care when R1 was admitted at the facility 5-30-24. R1’s Power of Attorney (POA) was informed, and an application was sent by POA to obtain dental insurance. The dental insurance card came on 04-01-25 and an appointment for dental care was obtained on 04-14-25. Further information obtained from record review revealed a pediatrist visited the facility on 08-4-24 to cut R1’s toenails.
Continued 809-C....
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Abdoulaye Zerbo
LICENSING EVALUATOR SIGNATURE:

DATE: 05/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2025
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 18-AS-20240806084343
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: SMITH ROAD ASSISTED LIVING
FACILITY NUMBER: 331881421
VISIT DATE: 05/21/2025
NARRATIVE
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LPA conducted interviews with staff and residents and information obtained revealed the residents have dental appointment when they request it.

Based on the evidence, the allegation mentioned above is UNSUBSTANTIATED. A finding that the complaint is UNSUBSTANTIATED means 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 at this time.

An exit interview was conducted where this report, LIC9099 was discussed and provided to Administrator Ma Satchel Lecita.

SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Abdoulaye Zerbo
LICENSING EVALUATOR SIGNATURE:

DATE: 05/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2