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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331881421
Report Date: 08/08/2025
Date Signed: 08/08/2025 04:19:59 PM

Substantiated


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
08/26/2024 and conducted by Evaluator Abdoulaye Zerbo
COMPLAINT CONTROL NUMBER: 18-AS-20240826183736
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: 9DATE:
08/08/2025
UNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Veronica JacksonTIME COMPLETED:
04:30 PM
ALLEGATION(S):
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Staff did not report an incident involving resident in care as required.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Abdoulaye Zerbo conducted an unannounced visit to deliver findings on the allegation listed above. LPA Abdoulaye was greeted and granted entrance by staff Veronica Jackson. LPA identified himself and discussed the purpose of the visit.
It was alleged staff did not report an incident involving a resident in care as required. LPA conducted an interview with the licensee who confirmed they did not report an incident occurring on 07/31/2024, involving Resident 1 (R1), to the Long Term Care Ombudsman (LTCO) within the time frame required by law. A review of the Unusual Incident/Injury Report dated 08/01/2024 revealed the LTCO was notified on 08/19/2024. This corroborates the time frame required by law was not met.
Based on interviews and records review, the allegation that staff did not report an incident involving a resident as required was determined to be substantiated. A substantiated finding means the allegation is valid because the preponderance of the evidence standard has been met. Pursuant to the California Code of Regulations, Title 22, Division 6, Health and Safety Code, a deficiency is cited on the attached LIC 9099-D.
An exit interview was conducted where this report, LIC9099D and appeal rights were discussed and provided to Administrator Ma Satchel Lecita.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Abdoulaye Zerbo
LICENSING EVALUATOR SIGNATURE:

DATE: 08/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2025
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-20240826183736
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/08/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/29/2025
Section Cited
CCR
87211(b)
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87211 Reporting Requirements
(b)Any suspected physical abuse that results in serious bodily injury of an elder or dependent adult shall be reported to the local ombudsman, the corresponding licensing agency, and the local law enforcement agency within two (2) hours as required by Welfare and Institutions Code Section 15630(b)(1).
This requirement is not met as evidenced by:
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Licensee stated they will schedule training for themselves and all staff on mandated reporting requirements. Proof of training will be submitted to the Department by the POC due date
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Based on interviews, the licensee did not comply with the section cited above, assuring the incident was reported to the local ombudsman within 2 hours of the incident, which poses a potential health and safety risk to residents 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: Anthony Perez
LICENSING EVALUATOR NAME: Abdoulaye Zerbo
LICENSING EVALUATOR SIGNATURE:

DATE: 08/08/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2