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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331881430
Report Date: 06/16/2025
Date Signed: 06/17/2025 01:43:41 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
02/26/2024 and conducted by Evaluator Valerie Flores
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20240226122805
FACILITY NAME:CASA DEL SOL RESIDENTIALFACILITY NUMBER:
331881430
ADMINISTRATOR:KHAN, MUSARRATFACILITY TYPE:
740
ADDRESS:27830 BRODIAEA AVENUETELEPHONE:
(909) 282-2316
CITY:MORENO VALLEYSTATE: CAZIP CODE:
92555
CAPACITY:6CENSUS: 6DATE:
06/16/2025
UNANNOUNCEDTIME BEGAN:
03:35 PM
MET WITH:Licensee, Masurrat KhanTIME COMPLETED:
05:05 PM
ALLEGATION(S):
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Staff do not ensure residents' care needs are met
INVESTIGATION FINDINGS:
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On 6/16/2025, Licensing Program Analyst (LPA) Valerie Flores conducted an unannounced visit to the facility for the purpose of delivering findings of the above allegation. LPA met with Licensee, Massurat Khan, who was informed of the purpose of the visit. LPA was granted entry, and LPA conducted a tour of the interior/exterior areas of the facility.
It was alleged that staff do not ensure residents’ care needs are being met. This was alleged due to facility advertising dementia care and did not supply adequate staffing to support Resident 1’s (R1) cognitive impairment. Through interviews conducted, it was alleged that R1 was experiencing wandering behaviors not identified during the pre-appraisal assessment and was not divulged in the physicians report obtained prior to R1s admission into the facility. Information obtained from a confidential witness revealed there were no concerns with the actual care being provided to R1 by the staff but there were concerns of staff complaining of the level of care staff had to provide to R1; such services were advertised by the facility.

(Continue to LIC9099C)

Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Valerie Flores
LICENSING EVALUATOR SIGNATURE:

DATE: 06/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2025
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 7
Control Number 18-AS-20240226122805
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: CASA DEL SOL RESIDENTIAL
FACILITY NUMBER: 331881430
VISIT DATE: 06/16/2025
NARRATIVE
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Through file review and interviews, facility staff did not submit incident reports to the Department regarding R1’s behavioral changes, the staff did not document R1’s observed changes of behavior, and the Licensee did not develop a written care plan based on the observation of R1’s alleged new condition as advertised in the Admission Agreement signed by R1, R1’s responsible party, and Licensee.

Information revealed the facility staff did not conduct a reappraisal of R1’s suspected new condition. Per Title 22, Section 87466, a licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional, and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. Furthermore, Licensee is required to conduct a reappraisal of the resident, if the residents are experiencing physical, mental, cognitive, behavioral and/or functional changes per section 87463.

Based on file review and interviews, the preponderance of evidence standard has been met. Therefore, the above allegation is substantiated. California Code of Regulations Title 22 is being cited on the attached LIC 9099 D. An exit interview was conducted, and a copy of this report LIC 9099D, and appeal rights were reviewed and provided.
SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Valerie Flores
LICENSING EVALUATOR SIGNATURE:

DATE: 06/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 18-AS-20240226122805
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: CASA DEL SOL RESIDENTIAL
FACILITY NUMBER: 331881430
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/16/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/27/2025
Section Cited
CCR
87463(b)
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The reappraisal shall document significant changes in the resident's physical, mental, cognitive, behavioral, or functional condition, including those required to be documented as specified in Section 87466, Observation of the Resident. This requirement was not met as evidence by:
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Licensee will create a training of Title 22, 87211, reporting requirements, and will document any relative incidents that affect the health and safety of the residents in care. Proof of training will be forwarded to LPA via email.
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Based on record review and interviews, licensee did not conduct a reappraisal for one (1) out of two (2) residents when there was a change of Resident #1 (R1) mental and behavioral condition which posed a potential Health and Safety risk to the residents in care.
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(This is an amended version of the original report.)
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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: Rikesha Stamps
LICENSING EVALUATOR NAME: Valerie Flores
LICENSING EVALUATOR SIGNATURE:

DATE: 06/16/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 7
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
02/26/2024 and conducted by Evaluator Valerie Flores
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20240226122805

FACILITY NAME:CASA DEL SOL RESIDENTIALFACILITY NUMBER:
331881430
ADMINISTRATOR:KHAN, MUSARRATFACILITY TYPE:
740
ADDRESS:27830 BRODIAEA AVENUETELEPHONE:
(909) 282-2316
CITY:MORENO VALLEYSTATE: CAZIP CODE:
92555
CAPACITY:6CENSUS: 6DATE:
06/16/2025
UNANNOUNCEDTIME BEGAN:
03:35 PM
MET WITH:Licensee, Masurrat KhanTIME COMPLETED:
05:05 PM
ALLEGATION(S):
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Illegal eviction
INVESTIGATION FINDINGS:
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It was alleged R1 was unlawfully evicted from the facility due to the Licensee not being able to accommodate R1’s needs. R1 was accepted into the facility on 12/30/23 and was given an eviction notice on 1/15/2024. Interviews were conducted and information revealed R1 was living in the facility for a duration of five (5) weeks and the Licensee had not attempted to complete a reappraisal during the time R1 was residing at the facility. The licensee did not comply with Title 22, Section 87224, Eviction Procedures, due to the Licensee not completing a reappraisal and not discussing with a physician in regard to the reappraisal; believing facility was not an appropriate fit for R1.

Based on file review and interviews, the preponderance of evidence standard has been met. Therefore, the above allegation is substantiated. California Code of Regulations Title 22 is being cited on the attached LIC 9099D. An exit interview was conducted, and a copy of this report LIC 9099D, and appeal rights were reviewed and provided.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Valerie Flores
LICENSING EVALUATOR SIGNATURE:

DATE: 06/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 7
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
02/26/2024 and conducted by Evaluator Valerie Flores
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20240226122805

FACILITY NAME:CASA DEL SOL RESIDENTIALFACILITY NUMBER:
331881430
ADMINISTRATOR:KHAN, MUSARRATFACILITY TYPE:
740
ADDRESS:27830 BRODIAEA AVENUETELEPHONE:
(909) 282-2316
CITY:MORENO VALLEYSTATE: CAZIP CODE:
92555
CAPACITY:6CENSUS: 6DATE:
06/16/2025
UNANNOUNCEDTIME BEGAN:
03:35 PM
MET WITH:Licensee, Masurrat KhanTIME COMPLETED:
05:05 PM
ALLEGATION(S):
1
2
3
4
5
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7
8
9
Staff do not have appropriate training
INVESTIGATION FINDINGS:
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It was alleged staff are not trained on how to manage residents with dementia. In addition, it was alleged staff encountered R2 yelling and cursing at staff and displaying aggressive behavior towards staff. Interviews were conducted and facility records were reviewed; information revealed in the facility’s written plan of operations, if a residents aggressive behavior poses a threat to the resident, other residents in care, and/or staff, the facility may elect to call 9-1-1 and have the resident discharged for a comprehensive medical and psychiatric evaluation in a clinical setting. Through records reviewed and interviews, staff complied with what was outlined in the facility’s written Plan of Operation. Through files reviewed, facility attained records of appropriate trainings that support staff with managing the care and supervision of residents with dementia, and trainings that assist staff with redirecting and mitigating incidents with dementia care residents displaying combative behaviors.

(Continue to LIC 9099C)
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Valerie Flores
LICENSING EVALUATOR SIGNATURE:

DATE: 06/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 5 of 7
Control Number 18-AS-20240226122805
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: CASA DEL SOL RESIDENTIAL
FACILITY NUMBER: 331881430
VISIT DATE: 06/16/2025
NARRATIVE
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Based on interviews and files reviewed, the allegation of staff does not have appropriate training is unfounded. A finding of Unfounded means the allegation could not have happened, is false, and/or is without a reasonable basis.
An exit interview was conducted, and a copy of this report was reviewed and provided to Licensee, Masurrat Khan.
SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Valerie Flores
LICENSING EVALUATOR SIGNATURE:

DATE: 06/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2025
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 18-AS-20240226122805
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: CASA DEL SOL RESIDENTIAL
FACILITY NUMBER: 331881430
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/16/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/27/2025
Section Cited
CCR
87224(a)(4)
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If, after admission, it is determined that the resident has a need not previously identified and a reappraisal has been conducted ..., and the licensee and the person who performs the reappraisal believe that the facility is not appropriate for the resident.
This requirement was not met as evidence by:
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Licensee stated she will have all upper management read Title 22, section 87224, Evictions Procedures and submit a signed document to LPA verifying the procedures were read. This document will be delivered to LPA via email.
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Bases on file review and interviews, Licensee issued an eviction notice to one (1) out of two (2) residents without conducting a reappraisal of the need not previously identified in the pre-admission assessment which poses a potential Health and Safety risk to the residents in care.
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(This is an amended version of the original report.)
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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: Rikesha Stamps
LICENSING EVALUATOR NAME: Valerie Flores
LICENSING EVALUATOR SIGNATURE:

DATE: 06/16/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2025
LIC9099 (FAS) - (06/04)
Page: 7 of 7