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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 336426029
Report Date: 11/28/2023
Date Signed: 11/28/2023 10:30:56 AM

Substantiated


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
06/22/2023 and conducted by Evaluator Melody Brown
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20230622095316
FACILITY NAME:CALOAKS SENIOR LIVINGFACILITY NUMBER:
336426029
ADMINISTRATOR:AMELIA ALADINFACILITY TYPE:
740
ADDRESS:3891 POLK STREETTELEPHONE:
(951) 689-6162
CITY:RIVERSIDESTATE: CAZIP CODE:
92505
CAPACITY:74CENSUS: 60DATE:
11/28/2023
ANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Licensee/Administrator Amelia AladinTIME COMPLETED:
10:40 AM
ALLEGATION(S):
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Facility staff sold a television to a resident in care.
INVESTIGATION FINDINGS:
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On 11/28/2023 at 10:00 AM Licensing Program Analyst (LPA) Melody Brown met with Administrator Amelia Aladin at Community Care Licensing Division (CCLD) Adult and Senior Care (ASC) Regional Office to deliver the findings of the above allegation. LPA Brown explained the purpose of the requested Office Visit. The investigation consisted of observation, interviews and a review of pertinent documentation.

The investigation was conducted by LPA Melody Brown. The investigation consisted of records review and interviews with relevant parties. The allegation indicates that Facility staff sold a television to a resident in care. LPA Brown obtained evidence to corroborate the allegation. Through the information gathered during the investigation, it was confirmed by interviews and documents review that a facility staff sold a television to a resident in care. Interview with Staff #2 (S2) indicated knowledge of Staff #3 (S3) selling a 55 inches television to Resident #1 (R1). Staff #1 (S1) reported to LPA Brown that S1 was just recently made aware of S3 selling a 55 inches television to R1. *** Continuation in LIC9099C ***
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 11/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/28/2023
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 56-AS-20230622095316
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: 11/28/2023
NARRATIVE
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Licensee/Administrator Amelia Aladin informed LPA Brown that all staff at the facility were informed on their New Staff Orientation that they are not allowed to sell their personal belongings to the residents at the facility. Licensee/Administrator Aladin added that a staff is prohibited from selling their personal belongings like a television to a resident due to conflict of interest which were all discussed to all new hired staff at the facility. Interview with Staff #3 revealed that S3 sold the 55 inches television to R1. Interview with Resident #5 (R5) indicated knowledge of S3 selling a 55 inches television to R1. Per documents review, LPA Brown observed 55 inches television indicated in R1’s list of Personal Property and Valuables when R1 moved out of the facility on 06/19/2023.

Based on LPA Brown’s document review and interviews, the preponderance of evidence standard has been met, and therefore the above allegation of Facility staff sold a television to a resident in care is found to be SUBSTANTIATED. A finding that the complaint is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met. California Code of Regulations, (Title 22, Division 6 & Chapter 8) is being cited on the attached LIC9099D.

An exit interview was conducted where this report, LIC9099, LIC9099D, and Appeal Rights were discussed and provided to Licensee/ Administrator Amelia Aladin.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 11/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/28/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 56-AS-20230622095316
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/28/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/08/2023
Section Cited
CCR
87411(a)
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87411 Personnel Requirements – General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more,… This requirement is not met as evidenced by:
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The Licensee stated to train all staff on CCR 87411(a) and submit proof of Training Log to LPA Brown at Plan of Correction (POC) due date.
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Based on observations, interview and records review, the Licensee did not comply with the section cited above by allowing Staff #3 (S3) violate their facility policy by selling a television to Resident #1 (R1) which poses potential 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: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 11/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/28/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 5
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
06/22/2023 and conducted by Evaluator Melody Brown
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20230622095316

FACILITY NAME:CALOAKS SENIOR LIVINGFACILITY NUMBER:
336426029
ADMINISTRATOR:AMELIA ALADINFACILITY TYPE:
740
ADDRESS:3891 POLK STREETTELEPHONE:
(951) 689-6162
CITY:RIVERSIDESTATE: CAZIP CODE:
92505
CAPACITY:74CENSUS: 60DATE:
11/28/2023
ANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Licensee/Administrator Amelia AladinTIME COMPLETED:
10:40 AM
ALLEGATION(S):
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Facility staff is financially abusing a resident in care.
INVESTIGATION FINDINGS:
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On 11/28/2023 at 10:00 AM Licensing Program Analyst (LPA) Melody Brown met with Administrator Amelia Aladin at Community Care Licensing Division (CCLD) Adult and Senior Care (ASC) Regional Office to deliver the findings of the above allegation. LPA Brown explained the purpose of the requested Office Visit. The investigation consisted of observation, interviews and a review of pertinent documentation.

The investigation was conducted by LPA Melody Brown. The investigation consisted of records review and interviews with relevant parties. The allegation indicates that Facility staff is financially abusing a resident in care. LPA Brown did not find evidence to corroborate the allegation. Interviews with Resident #3 (R3), Resident #5 (R5), Resident #6 (R6), Resident #8 (R8), Resident #10 (R10) and Resident #11 (R11) indicated that no staff at the facility is financially abusing a resident.

*** Continuation in LIC9099C ***
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 11/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/28/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 56-AS-20230622095316
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: 11/28/2023
NARRATIVE
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Five (5) of five (5) staff interviews indicated they are not aware of an incident that happened at the facility where a staff is financially abusing a resident. Interviews with staff revealed that they all treat their residents with respect and kindness and no staff at the facility is financially abusing a resident in care.

Based on interviews and records review, the allegation Facility staff is financially abusing a resident in care 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/Administratro Amelia Aladin.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 11/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/28/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5