331881582-3-30-2026-18-AS-APEZ-DSYTG7-20260409144240

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 331881582
Report Date: 03/30/2026
Date Signed: 03/30/2026 09:09:15 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
07/21/2025 and conducted by Evaluator Valerie Flores

COMPLAINT CONTROL NUMBER: 18-AS-20250721211454

FACILITY NAME:	MURRIETA GARDENS		FACILITY NUMBER:	331881582
ADMINISTRATOR:	KAVENAUGH, BRITTANY		FACILITY TYPE:	740
ADDRESS:	24200 MONROE AVE		TELEPHONE:	(951) 600-7676
CITY:	MURRIETA	STATE: CA	ZIP CODE:	92562
CAPACITY:	126	CENSUS: 40	DATE:	03/30/2026
		UNANNOUNCED	TIME BEGAN:	08:45 PM
MET WITH:	Administrator Kylee Carter		TIME COMPLETED:	09:45 PM

ALLEGATION(S):

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Staff did not prevent a resident from sustaining a fracture while in care

INVESTIGATION FINDINGS:

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On 3/30/2026, Licensing Program Analyst (LPA) Valerie Flores conducted an unannounced visit to the facility for the purpose of delivering the investigative findings into the allegation listed above. LPA Flores met with Administrator Kylee Carter and explained the purpose of the visit. The investigation was conducted by the Investigation Branch and is summarized as follows:

Information received alleged staff did not prevent Resident #1 (R1) from sustaining a fracture while in care. Staff interviews revealed that R1 is known to be a fall risk but primarily uses a wheelchair. Administrator reports R1 exhibited signs of pneumonia and R1’s responsible person requested R1 to be transferred to the doctors for evaluation. During that hospital visit, a chest x-ray was taken of R1. Administrator reported that the X-Ray revealed multiple rib fractures.

(Continue to LIC9099C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Valerie Flores
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)

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Control Number 18-AS-20250721211454

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: MURRIETA GARDENS	FACILITY NUMBER: 331881582
	VISIT DATE: 03/30/2026

NARRATIVE

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(Continuation from LIC9099)

Administrator reported that the hospital staff reviewing the x-ray elevated their concerns when it was later discovered that prior chest x-rays showed the rib fractures. A records review was conducted of the facility’s Unusual Incident Reports. A report dated 6/29/2025 documented an unwitnessed fall in which R1 was found seated on the floor, at the base of the couch. She was transported to the hospital for evaluation, where it was confirmed that no injuries were sustained. A report dated 7/20/2025 documented that R1 had exhibited signs of pneumonia and was transported to the hospital by their responsible. This incident is the direct subject of the current investigation. Other than these two reports, no additional incidents involving R1 have been reported. Interview with R1 report that R1 slipped off the couch earlier that year but does not recall sustaining any injuries. An interview with R1 and their responsible person report that R1 was in a major car accident in the 1990’s causing R1 to sustain multiple rib fractures. R1 responsible person reports that the prior fracture was still shown in the x-ray, but the area of the fractures is healed. Interview with R1 confirmed that there is no residing pain from the prior rib fractures and does not recall the last time when R1 experienced pain in that area. Attempts to interview Witness #1 (W1) were unsuccessful. Additional information received document “Per provider, radiologist re-reviewed imaging from previous visit and the rib fractures were present at the time, just didn’t get notated. Plan for DC back to Murrieta Gardens”.

Based on interviews and records review, the allegation of “staff did not prevent a resident from sustaining a fracture while in care” is deemed unsubstantiated. A finding that the complaint is UNSUBSTANTIATED means although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegations are unsubstantiated at this time.

An exit interview was conducted where this report was discussed and provided to Administrator.

SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Valerie Flores
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)

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