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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331881480
Report Date: 08/15/2025
Date Signed: 08/15/2025 11:38:40 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
06/09/2025 and conducted by Evaluator Seo Jeon
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20250609123952
FACILITY NAME:SAVANT OF RIVERSIDEFACILITY NUMBER:
331881480
ADMINISTRATOR:MOLLY BOWIEFACILITY TYPE:
740
ADDRESS:4609 ARLINGTON AVETELEPHONE:
(951) 462-1025
CITY:RIVERSIDESTATE: CAZIP CODE:
92504
CAPACITY:232CENSUS: 97DATE:
08/15/2025
UNANNOUNCEDTIME BEGAN:
10:40 AM
MET WITH:Molly Bowie, Executive DirectorTIME COMPLETED:
11:55 AM
ALLEGATION(S):
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Lack of supervision/neglect resulting in resident developing a pressure injury
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Seo Jeon conducted an unannounced visit to the facility to deliver findings of the above allegation. LPA met with Molly Bowie, Executive Director and informed them of the LPA's visit. The Department investigation involved interviews with staff, residents, and review of records.

On 06-09-2025, Community Care Licensing (CCLD) received a complaint report with the above allegation.

It was alleged lack of supervision/neglect resulting in resident developing a pressure injury. Information received stated Resident #8 (R8) had pressure injury that was not treated. LPA’s review of resident file revealed R8 was admitted into the facility in September 2023 and had been under hospice care since March 2024 due to conditions unrelated to the wound care.

Continued on LIC9099-C.....
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Seo Jeon
LICENSING EVALUATOR SIGNATURE:

DATE: 08/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2025
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-20250609123952
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: SAVANT OF RIVERSIDE
FACILITY NUMBER: 331881480
VISIT DATE: 08/15/2025
NARRATIVE
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R8 passed away while receiving hospice care in April 2025 at the facility. LPA conducted review of progress notes documenting routine hospice visits for comfort and wound care. LPA’s review of R8’s hospice records and care plan revealed R8 required assistance with all activities of daily living (ADLs) including repositioning. According to hospice records, facility staff received training on March 3, 2025, for pressure injury management from the hospice agency, including guidance on proper reposition techniques, importance of maintaining strict reposition intervals, and incontinent care routines.

Interviews conducted with the Administrator and three (3) staff members assigned to R8 revealed that staff followed hospice-provided instructions regarding wound care, repositioning procedures/routines, and incontinent care. LPA’s review of the hospice agency wound care records indicated R8’s wound was improving. R8 had received routine care from the facility staff, in addition the facility staff confirmed they followed the facility’s procedures such as, routine room checks and repositioning, as well as those from the hospice agency.

Based on record review and staff interviews, this allegation is Unsubstantiated. A finding that the complaint is UNSUBSTANTIATED means the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred.



An exit interview was conducted where a copy of this report was provided.
SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Seo Jeon
LICENSING EVALUATOR SIGNATURE:

DATE: 08/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2025
LIC9099 (FAS) - (06/04)
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