336426029-5-22-2023-56-AS-EMAN-CS4MZL-20230523100320

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 336426029
Report Date: 05/22/2023
Date Signed: 05/22/2023 11:43:38 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/24/2022 and conducted by Evaluator Melody Brown

PUBLIC

COMPLAINT CONTROL NUMBER: 56-AS-20220624172322

FACILITY NAME:	CALOAKS SENIOR LIVING		FACILITY NUMBER:	336426029
ADMINISTRATOR:	AMELIA ALADIN		FACILITY TYPE:	740
ADDRESS:	3891 POLK STREET		TELEPHONE:	(951) 689-6162
CITY:	RIVERSIDE	STATE: CA	ZIP CODE:	92505
CAPACITY:	74	CENSUS: 51	DATE:	05/22/2023
		ANNOUNCED	TIME BEGAN:	11:30 AM
MET WITH:	Licensee/Administrator Amelia Aladin		TIME COMPLETED:	11:45 AM

ALLEGATION(S):

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Resident sustained injury while in care due to lack of supervision.

INVESTIGATION FINDINGS:

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On 05/22/2023 at 11:30 AM, Licensing Program Analysts (LPAs) Melody Brown and Mary Rico met with Licensee/Administrator Amelia Aladin at Community Care Licensing Division (CCLD) Adult and Senior Care (ASC) Regional Office to deliver the findings of the above allegation. LPAs Brown and Rico explained the purpose of the Office Visit. The investigation consisted of file review, interviews with staff and residents as well as observation.

The investigation was conducted by LPA Brown. The investigation consisted of file review and interviews with relevant parties. The allegation indicates resident sustained injury while in care due to lack of supervision. During the investigation, LPA Brown did not find evidence to corroborate the allegation. Interviews with staffs and residents indicated that staffs are providing appropriate supervision to all the residents at the facility and they are checking on residents in care every two(2) hours and more if needed and there’s no incident happened at the facility that a resident sustained injury while in care due to lack of supervision. *** Continuation in LIC9099C ***

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE:	DATE: 05/22/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2023

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 56-AS-20220624172322

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: CALOAKS SENIOR LIVING	FACILITY NUMBER: 336426029
	VISIT DATE: 05/22/2023

NARRATIVE

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During the facility visit last 06/29/2022, LPA Brown observed that sufficient number of staffs are working at the facility providing care and supervision to residents in care. LPA Brown observed three (3) caregivers, one (1) Medical Technician, one (1) Licensed Vocational Nurse, one (1) housekeeping staff and one (1) Maintenance staff. Moreover, during the facility visit last 06/29/2022, Health and Wellness Director Melissa Bridges reported to LPA Brown that all staffs at the facility are checking on residents every two (2) hours and staffs checked on a resident every hour if needed. In addition, LPA Brown reviewed the facility’s June 2022 Staff Schedule and it indicated sufficient number of staffs working at the facility per shift schedule to provide care and supervision to all the residents in care. Also, LPA Brown reviewed R1's Medical Records and LPA Brown observed no indication of reported injury observed on R1 last 06/23/2022.

Based on interviews and records review, the allegation resident sustained injury while in care due to lack of supervision is UNSUBSTANTIATED. A finding of unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur.

An exit interview was conducted, where this report (LIC9099) was discussed and provided to Licensee/Administrator Amelia Aladin.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE:	DATE: 05/22/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2023

LIC9099 (FAS) - (06/04)

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