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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 336426029
Report Date: 04/08/2025
Date Signed: 05/19/2025 01:16:22 PM

Substantiated


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
06/30/2021 and conducted by Evaluator Beena Singh
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20210630075559
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: 51DATE:
04/08/2025
UNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Facility Adminstrator-Amelia Aladin TIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Licensee failed to provide immediate written notice of resident’s death to the public administrator.
INVESTIGATION FINDINGS:
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First Allegation: Licensee failed to provide immediate written notice of resident’s death to the public administrator.

Licensing Program Analysts (LPA) Beena Singh conducted an unannounced visit to the facility to deliver findings on a complaint alleging, Licensee failed to provide immediate written notice of resident’s death to the public administrator.

LPA Singh met with Amelia Aladin Licensee/Administrator, facility representative, and was granted entry into the facility. The investigation conducted by Department staff consisted of interviews and records review.
During this investigation, LPA interviewed staff and reviewed facility files including copy of SSI checks and facility notes. Copies of pertinent information was obtained for the file. Due to health issues, Resident(R1) was hospitalized and died at the hospital.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Beena Singh
LICENSING EVALUATOR SIGNATURE:

DATE: 04/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2025
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-20210630075559
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: 04/08/2025
NARRATIVE
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Facility notified public administrator at the time of resident's hospitalization; facility notifies relevant agencies in the event of the death of the patient in hospital, including Community Care Licensing Division (CCLD), Social security Administration (SSA)and Care coordination Agencies (CCA) on 2/2/2021 within the reporting time requirement. However, Licensee failed to provide immediate written notice of resident’s death to the public administrator- responsible for the resident due to no known kin at the time.
Therefore, based on record reviews, this allegation is deemed SUBSTANTIATED. A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. A citation will be issued in accordance with the California Code of Regulations (Title 22, Division 6, Chapter 8).

An exit interview was conducted where this report, LIC9099 and LIC 9099 D, Appeal Rights were discussed and provided to Facility Licensee/ administrator Amelia Aladin.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Beena Singh
LICENSING EVALUATOR SIGNATURE:

DATE: 04/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2025
LIC9099 (FAS) - (06/04)
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