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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 336426029
Report Date: 02/27/2025
Date Signed: 05/30/2025 10:23:22 AM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO 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
04/19/2021 and conducted by Evaluator Beena Singh
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20210419135612
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: 57DATE:
02/27/2025
UNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Licensee/Administrator Amelia AladinTIME COMPLETED:
12:30 PM
ALLEGATION(S):
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Facility staff do not change resident bedding regularly.
Facility did not provide required furniture for residents in care.
Facility staff do not safeguard resident's personal belongings.
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Beena Singh and LPA Melody Brown conducted an unannounced visit to deliver findings on the allegations listed above. LPAs met with Licensee/Administrator Amelia Aladin and explained the purpose of the visit. The investigation consisted of staff interviews, client interviews, LPAs observation and record reviews.

The investigation was done by LPAs Beena Singh and Melody Brown.

The first allegation indicates Facility staff do not change resident bedding regularly.
During the investigation, LPAs were not able to corroborate the allegation. Interviews with six (6) out of six(6) residents and 6 of 6 staffs interviewed on 2/26/2025,reported that facility staff keep residential bedding clean and change them regularly.

Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Beena Singh
LICENSING EVALUATOR SIGNATURE:

DATE: 02/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2025
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 6
Control Number 18-AS-20210419135612
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: CALOAKS SENIOR LIVING
FACILITY NUMBER: 336426029
VISIT DATE: 02/27/2025
NARRATIVE
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During the facility visit on 02/27/2025, LPAs Singh and LPA Brown observed residents bedding has been changed and been done regularly.

Second allegation indicates Facility did not provide required furniture for residents in care. Interviews with six(6) out of six(6) residents and six(6) out of six(6) staffs interviewed on 2/26/2025 reported that there is required furniture in all the residents’ bedrooms.

During the facility visit on 02/27/2025, LPAs Singh and LPA Brown observed there are required furniture in the resident’s room, including for each resident, a chair, night stand, a lamp, or lights sufficient for reading, and a chest of drawers.

Third allegation indicates, Facility staff do not safeguard resident's personal belongings.
During the investigation, LPA Singh was not able to corroborate the allegation. Interviews with six (6) out of 6 staffs interviewed 02/26/2025 reported that sometimes resident's personal belongings do get lost but staff ensures residents get them back. Interviews with six(6) out six(6) residents indicated no issues or concerns.

Based on interview and record review in investigation, the allegations listed above is deemed UNSUBSTANTIATED. A finding that the complaints are UNSUBSTANTIATED means although the allegation may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. During today’s visit, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations


An exit interview was conducted and this report LIC9099, LIC 9099C being discussed and provided to Licensee/Administrator Amelia Aladin.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Beena Singh
LICENSING EVALUATOR SIGNATURE:

DATE: 02/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 18-AS-20210419135612
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: CALOAKS SENIOR LIVING
FACILITY NUMBER: 336426029
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/27/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type B
03/03/2025
Section Cited
CCR
87307(a)(3)(C)
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87307 Personal Accommodations and Services (a) Living accommodations and grounds shall be related to the facility's function. The facility shall be large enough to provide comfortable living accommodations and privacy for the residents…(3) Equipment and supplies necessary for personal care and maintenance of adequate…(C) Clean linen, including blankets, bedspreads, top bed sheets…The quantity shall be sufficient to permit changing at least once per week or more often…
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Licensee stated to train all staff on CCR 87307(a)(3)(C) and submit proof to LPA Singh by the Plan of Correction(POC) due date.
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Based on interviews, Licensee did not comply with the section cited above by not ensuring that residents bedding was changed regularly as required which poses a potential health, safety and personal rights risk to resident in care.1977859892
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Deficiency Dismissed
Type B
03/03/2025
Section Cited
CCR
87307(a)(3)(B)
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87307 Personal Accommodations and Services (a) Living accommodations and grounds shall be related to the facility's function. The facility shall be large enough to provide comfortable living accommodations and privacy for the residents…(3) Equipment and supplies necessary for personal care and maintenance of adequate…(B) Bedroom furniture, which shall include, for each resident, a chair, a night stand, a lamp or lights…
This requirement was not met as evidenced by:
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Licensee stated to provide chairs to all resident bedrooms and submit proof to LPA Singh by the Plan of Correction (POC) due date.
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Based on interviews, Licensee did not comply with the section cited above by not ensuring that chairs were provided to residents as required which poses a potential health, safety and personal rights risks 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: Beena Singh
LICENSING EVALUATOR SIGNATURE:

DATE: 02/27/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 18-AS-20210419135612
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: CALOAKS SENIOR LIVING
FACILITY NUMBER: 336426029
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/27/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type B
03/03/2025
Section Cited
CCR
87217(b)
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87217 Safeguards for Resident Cash, Personal Property, and Valuables...(b) Every facility shall take appropriate measures to safeguard residents' cash.. personal property and valuables ... entrusted to the licensee or facility staff. The licensee shall give the residents receipts for all such articles...

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Licensee stated to train all staff on CCR 87217(b) and submit proof to LPA Singh by the Plan of Correction (POC) due date.
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Based on interviews and record review, facility did not follow safeguards for residents’ personal property due to several residents having their personal belongings being stolen which poses a potential health, safety, or Personal Rights risk to persons 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: Beena Singh
LICENSING EVALUATOR SIGNATURE:

DATE: 02/27/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2025
LIC9099 (FAS) - (06/04)
Page: 6 of 6