336426029-1-20-2026-56-AS-EMAN-DRF257-20260218160505

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 336426029
Report Date: 01/20/2026
Date Signed: 01/20/2026 01:43:48 PM

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
01/16/2026 and conducted by Evaluator Beena Singh

PUBLIC

COMPLAINT CONTROL NUMBER: 56-AS-20260116093031

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: 52	DATE:	01/20/2026
		UNANNOUNCED	TIME BEGAN:	11:30 AM
MET WITH:	Facility Administrator-Amelia Aladin		TIME COMPLETED:	02:20 PM

ALLEGATION(S):

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Due to lack of staff, resulted in unwitnessed fall and resident sustaining injuries.

INVESTIGATION FINDINGS:

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On 1/20/2026, Licensing Program Analyst (LPA) Beena Singh conducted an unannounced visit to the facility to initiate and deliver findings on a complaint alleging Due to lack of staff, resulted in unwitnessed fall and resident sustaining injuries. LPA Singh met with manager/LVN-Melissa Bridges, facility representative, and was granted entry into the facility. Facility Licensee/Administrator Amelia Aladin arrived during this visit. The investigation conducted by LPA Singh consisted of interviews and records review.

Based on interviews with eight (8) out of eight (8) residents, none witnessed Resident #1’s fall in the hallway. However, Eight out of Eight residents indicated that staff ensure their safety, both day and night. Additionally, all eight residents interviewed stated that staff promptly call for emergency services, such as an ambulance, when needed, and provides good care to all residents in care

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Beena Singh
LICENSING EVALUATOR SIGNATURE:	DATE: 01/20/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/20/2026

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 56-AS-20260116093031

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: 01/20/2026

NARRATIVE

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Four (4) out four (4) staff reports, Resident #1 (R#1), who is known to be ambulatory and smokes, was returning to the facility after smoking, when he grabbed hallway side rails and began kneeling down. Upon being questioned by night shift staff, R#1 fell to the ground and appeared pale. Staff called 911, and while the ambulance was en route, R#1 stopped breathing. Following instructions from the 911 operator, staff initiated CPR. Paramedics arrive but was unable to revive R#1. Staff promptly informed family, police and death have been reported to the CDSS-CCLD.

LPA Singh concluded that there was insufficient evidence to prove the allegation that Due to lack of staff, resulted in un-witnessed fall and resident sustaining injuries.

Based on the evidence found during the investigation, the allegations listed Due to lack of staff, resulted in un-witnessed fall and resident sustaining injuries, 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) was discussed and provided to Facility manager/LVN-Melissa Bridges.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Beena Singh
LICENSING EVALUATOR SIGNATURE:	DATE: 01/20/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/20/2026

LIC9099 (FAS) - (06/04)

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