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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331881480
Report Date: 03/30/2026
Date Signed: 03/30/2026 03:50:02 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
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: 120DATE:
03/30/2026
UNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Molly Bowie, Executive DirectorTIME COMPLETED:
04:20 PM
ALLEGATION(S):
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Lack of supervision/neglect resulting in death of resident
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 purpose of LPA’s visit.

On 06-09-2025, Community Care Licensing (The Department) received a complaint report with the following allegation.

The allegation was lack of supervision/neglect resulting in death of resident. Information received indicated that Resident #1 (R1) did not receive assistance with their oxygen machine from the night shift staff members, resulting in R1’s death.

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

DATE: 03/30/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2026
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 3
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: 03/30/2026
NARRATIVE
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During the Department’s investigation, a comprehensive review of records and interviews with facility residents and staff members was conducted to ascertain the circumstances surrounding the incident.

The Department’s review of R1’s resident file revealed that R1 always required oxygen tank and oxygen concentrator. R1 also had cognitive condition that interfered with R1’s ability to perform activities of daily living. R1’s care plan indicated that R1 required maximum assistance with special care needs, such as two (2) hour safety checks and assistance with oxygen use.

The Department conducted interviews with two (2) staff members who were on duty on the night of R1’s death. Interview with both staff members revealed R1’s wellbeing was not monitored during the entire night shift. This lack of neglect and supervision was considered a contributing factor in R1’s death. Given R1’s diagnosed conditions and medical needs, regular monitoring of at least two (2) hours was a required standard of care.

It is important to note R1’s body was discovered by a staff member who worked the morning shift. The Department’s investigation provided enough information to corroborate the allegation of lack of supervision/neglect resulting in death of resident. Based on interviews conducted and records review, this allegation is substantiated.

A finding that the complaint is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met.

An immediate civil penalty of $500 is being assessed. In accordance with CCR Section 87468.2(a)(4), the determination of additional civil penalties for a violation that resulted in a death of resident, is pending and under review by the Department.

An exit interview was conducted where a copy of this report was provided, along with LIC9099C, LIC9099D, LIC421IM, and Appeal Rights were provided.

SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Seo Jeon
LICENSING EVALUATOR SIGNATURE:

DATE: 03/30/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 3
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/30/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/03/2026
Section Cited
CCR
87468.2(a)(4)
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87468 Additional Personal Rights of Residents in Privately Operated Facilities, (a) In addition to the rights listed in Section 87468.1, Personal Rights... (4) To care, supervision, and services that meet their individual needs... This requirement was not met as evidenced by:
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Licensee agrees to provide re-inservice all staff to safety/assurance checks, retrain all staff on what assisting oxygen assistance is. Licensee agrees to send proof of training by the POC due date to LPA via email.
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Based on interviews conducted and records review, staff's neglect/lack of supervison resulted in death of resident. This posed immediate health and safety risk to resident 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: Rikesha Stamps
LICENSING EVALUATOR NAME: Seo Jeon
LICENSING EVALUATOR SIGNATURE:

DATE: 03/30/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2026
LIC9099 (FAS) - (06/04)
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