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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331881480
Report Date: 08/20/2025
Date Signed: 08/20/2025 12:52:57 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
04/08/2025 and conducted by Evaluator Janette Romero
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20250408113819
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:
08/20/2025
UNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Wellness Coordinator, Breanna JonesTIME COMPLETED:
01:00 PM
ALLEGATION(S):
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Staff leave resident in soiled diapers for an extended period of time
Staff are not responding to resident's requests for assistance in a timely manner
Staff do not ensure that resident is provided with proper incontinence supplies
INVESTIGATION FINDINGS:
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On 8/20/2025, Licensing Program Analyst (LPA) Janette Romero conducted an unannounced visit to the facility to deliver findings regarding the allegations listed above. LPA met with Wellness Coordinator, Breanna Jones who was informed of the purpose of the visit.

Regarding the allegation, “Staff leave resident in soiled diapers for an extended period of time” it was alleged Resident 1 (R1) is left in soiled/wet diapers consistently for about 45 minutes to an hour. LPA reviewed R1’s physician’s report dated 03/13/2025 and the capacity for self-care subsection, “Able to Care for Own Toileting Needs” is marked “No”. R1 was interviewed and reported they wait approximately one and a half-to-two hours to receive incontinence care on a daily basis after calling the front desk for assistance. Three (3) staff were interviewed and reported R1 is constantly checked on and receives as needed incontinence assistance in a timely manner. One (1) of three (3) staff interviewed reported they check on R1 at least every 30 minutes where R1 will report whether they are soiled/wet and request or decline a brief change. One (1) of three (3) staff interviewed reported R1’s incontinent care refusals are not documented because R1 will initially decline a brief change but later request/agree to a brief change before the end of shift. Staff reported the facility does not document each time a resident receives incontinence care.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Carolyn Tuba
LICENSING EVALUATOR NAME: Janette Romero
LICENSING EVALUATOR SIGNATURE:

DATE: 08/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2025
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 5
Control Number 18-AS-20250408113819
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: 08/20/2025
NARRATIVE
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Eight (8) additional residents who were identified to require incontinent care were interviewed. Two (2) of eight (8) residents interviewed denied requiring incontinent care. Three (3) of eight (8) residents interviewed reported receiving incontinent care in a timely manner. However, three (3) of eight (8) residents interviewed reported waiting approximately two (2) to three (3) hours to receive incontinent care from staff after requesting staff's assistance. Based on interviews conducted, this allegation is substantiated.

Regarding the allegation, “Staff are not responding to resident's requests for assistance in a timely manner” it was alleged R1’s call light is not working properly so they are forced to call the front desk. LPA reviewed R1’s physician’s report dated 3/13/2025 and the mental condition subsection, “Able to Communicate Needs” is marked “Yes”. R1 was interviewed and reported their call light works properly but facility staff respond approximately forty-five minutes to an hour after R1 activates their call light, which prompts them to call the front desk. Three (3) staff interviewed reported having knowledge R1’s call light works properly. One (1) of three (3) staff interviewed reported they have accidentally activated R1’s call light evidenced by the call light illuminating which required staff to turn it off. A staff interview reported all residents’, including R1’s, call lights have been tested and found to be functioning properly. Nine (9) additional residents were interviewed of which one (1) reported being independent and not using their call light. Four (4) of nine (9) residents interviewed reported activating their call light and receiving timely assistance and waiting up to fifteen minutes. One (1) of nine (9) residents interviewed reported receiving assistance approximately thirty minutes after activating their call light. However, three (3) of nine (9) residents interviewed reported receiving assistance one (1) to three (3) hours after activating their call light for assistance. Administrator, Molly Bowie reported the facility's call light system does not give them the ability to send call log reports or view call light response times. Based on interviews conducted and records reviewed, this allegation is substantiated.
SUPERVISORS NAME: Carolyn Tuba
LICENSING EVALUATOR NAME: Janette Romero
LICENSING EVALUATOR SIGNATURE:

DATE: 08/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 18-AS-20250408113819
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: 08/20/2025
NARRATIVE
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Regarding the allegation, “Staff do not ensure that resident is provided with proper incontinence supplies” it was alleged R1’s incontinent supplies are the incorrect size. R1 was interviewed and reported when they moved into the facility, they immediately noticed the briefs provided by the facility were too small because they irritated their skin. Three (3) staff were interviewed and refuted the allegations. Two (2) of three (3) staff interviewed reported although the briefs provided by the facility seemed to be appropriately sized, R1 decided to purchase their preferred brand and size of briefs. One (1) of three (3) staff interviewed reported the brand of briefs the facility uses is sized larger than the standard measurements for that size and accommodates waist sizes greater than R1’s. One (1) of three (3) staff interviewed showed LPA the brand and size of briefs provided to R1, and LPA compared it to the briefs R1 reportedly uses. Based on the brief labels, the briefs R1 uses accommodate waist sizes that are up to twenty-two inches larger than the briefs provided to R1 by the facility. Based on interviews conducted and records reviewed, this allegation is substantiated. An exit interview was conducted and a copy of this report, LIC 9099-D, Confidential Names list (LIC 811) and Appeal Rights were reviewed with Wellness Coordinator, Breanna Jones. Administrator, Molly Bowie called Wellness Coordinator Jones and developed the plan of corrections with LPA.
SUPERVISORS NAME: Carolyn Tuba
LICENSING EVALUATOR NAME: Janette Romero
LICENSING EVALUATOR SIGNATURE:

DATE: 08/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 18-AS-20250408113819
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/20/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/29/2025
Section Cited
CCR
87625(b)(3)
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87625 Managed Incontinence
(b)(3) Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence. This requirement was not met as evidenced by:
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Administrator reported the facility will conduct an all staff training on 8/28/2025 regarding providing residents with timely incontinence care. POC will be emailed to LPA by close of business on 9/3/2025 to allow for any contingencies.
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Based on interviews conducted, four (4) of eight (8) residents reported waiting approximately two (2) to three (3) hours to receive incontinent care from staff after requesting staff's assistance. This poses a potential health risk to residents in care.
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Type B
08/29/2025
Section Cited
CCR
87468.2(a)(4)
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(a) (4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement was not met as evidenced by:
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Administrator reported the facility will conduct an all staff training on 8/28/2025 regarding appropriate call light response times. POC will be emailed to LPA by close of business on 9/3/2025 to allow for any contingencies.
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Based on interviews conducted, four (4) of nine (9) residents reported wait times ranging from 45 minutes to three (3) hours to receive staff assistance after activating their call light.This poses a potential health/safety/personal rights 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: Carolyn Tuba
LICENSING EVALUATOR NAME: Janette Romero
LICENSING EVALUATOR SIGNATURE:

DATE: 08/20/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 18-AS-20250408113819
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/20/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/03/2025
Section Cited
CCR
87307(a)(3)(D)
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(a)(3) Equipment and supplies necessary for personal care and maintenance of adequate hygiene practice shall be readily available to each resident. The resident may provide the following items; however, if the resident is unable or chooses not to provide them, the licensee shall assure provision of: (D) Hygiene items of general use such as soap and toilet paper. This requirement was not met as evidenced by:
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Administrator will work with corporate office to develop a practice to obtain appropriate incontinence supplies, if the facility's supply does not meet resident's needs. POC to be emailed to LPA by COB on 9/3/2025.
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Based on interviews conducted and records reviewed, the briefs R1 uses accommodate waist sizes that are up to twenty-two inches larger than the briefs provided to R1 by the facility. This poses a potential health/personal rights 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: Carolyn Tuba
LICENSING EVALUATOR NAME: Janette Romero
LICENSING EVALUATOR SIGNATURE:

DATE: 08/20/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5