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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 336427235
Report Date: 09/22/2024
Date Signed: 12/30/2024 12:47:49 PM

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
11/22/2023 and conducted by Evaluator Melody Brown
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20231122161045
FACILITY NAME:CORONA RESIDENTIAL CARE CENTER LLCFACILITY NUMBER:
336427235
ADMINISTRATOR:AHARON STRIKSFACILITY TYPE:
740
ADDRESS:1400 CIRCLE CITY DRTELEPHONE:
(951) 735-0252
CITY:CORONASTATE: CAZIP CODE:
92879
CAPACITY:125CENSUS: 84DATE:
09/22/2024
UNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Assistant Administrator Mary GonzalezTIME COMPLETED:
10:30 AM
ALLEGATION(S):
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Licensee does not ensure that facility grounds are free from hazards to residents in care.
Staff did not adequately supervise resident in care resulting in resident sustaining an injury while in care.
Staff did not provide assistance to resident in a timely manner.
INVESTIGATION FINDINGS:
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On 12/30/2024 at 09:15 AM, Licensing Program Analyst (LPA) Melody Brown made an unannounced visit to the facility to amend the report issued on 09/22/2024 regarding the findings of the above allegations. LPA Brown explained the purpose of the visit to a staff. Staff contacted Assistant Administrator Mary Gonzalez and informed of the visit. LPA Brown explained the purpose of the visit to Assistant Administrator Mary Gonzalez. The investigation consisted of file review, interviews with staffs 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 first allegation indicates Licensee does not ensure that facility grounds are free from hazards to residents in care. During the investigation, LPA Brown did not find evidence to corroborate the allegation. Interviews with seven (7) of seven (7) residents indicated that staffs at the facility ensure that the facility grounds are free from hazards and ***Continuation in LIC9099C***
**This an amended Complaint Investigation Report (LIC9099) that was issued on 09/22/2024***
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 12/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/30/2024
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 7
Control Number 56-AS-20231122161045
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: CORONA RESIDENTIAL CARE CENTER LLC
FACILITY NUMBER: 336427235
VISIT DATE: 09/22/2024
NARRATIVE
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there's no incident that the staffs at the facility did not ensure that the the facility grounds/backyard/ courtyard are free from hazards. LPA Brown unable to interview three (3) residents as Resident #1 (R1) passed away on 12/29/2023, and Resident #7 (R7) and Resident #9 (R) were sleeping. Interviews with nine (9) of nine (9) staffs indicated that they all ensure that the facility grounds/backyard/courtyard are free from hazards to residents. Interviews with nine (9) of nine (9) staffs revealed that no incident happened at the facility that they did not make sure that the facility grounds/backyard and courtyard are free from hazards. Six (6) of six (6) staffs interviewed stated that no incident happened at the facility that they did not ensure that the facility grounds/ backyard/courtyard are free from hazards to R1. Moreover, all staff interviewed reported that the facility grounds/backyard/courtyard were always maintained clean. During the facility visit on 11/30/2023 and 07/30/2024, LPA Brown observed the facility grounds/backyard/courtyard are free from hazards to residents and no potholes observed.

The second allegation indicates that Staff did not adequately supervise resident in care resulting in resident sustaining an injury while in care. Interviews with seven (7) of seven residents indicated that staffs at the facility are checking on them multiple times in a day. Seven (7) of seven (7) residents interviewed reported that staffs at the facility always checks on them and there's no incident that staffs at the facility did not check on them. LPA Brown unable to interview three (3) residents as R1 passed away on 12/29/2023, and R7 and R9 were sleeping. Interviews with nine (9) of nine (9) staffs indicated that they are checking on their residents every two (2) hours, more frequent if needed. Interviews with five (5) of six (6) staffs indicated that on 09/08/2023, staffs at the facility adequately supervise R1 and they all reported that R1 has a habit of arriving late at the facility after a night out with friends as during that time, R1 has his own vehicle which R1 parks at the facility back alley way. Interview with Staff #8 (S8) indicated that S8 was working at the facility on 09/08/2023 and S8 was informed by a skilled nursing staff that a resident was at the back alley of the facility and they both approached the resident observed and S8 stated that it was R1 that was at the back alley of the facility at around 12:00 AM. Moreover, S8 stated that S8 checked on R1 and R1 said that R1 wants to stay at the back alley and refused to go back to R1's room. S8 added that S8 checked back on R1 at around 01:30 AM and saw R1 fell from R1's motorized wheelchair and S8 immediately attended to R1 and S8 contacted Staff #9 (S9) for assistance to help R1 back on R1's motorized wheelchair. S8 stated that they observed bruises on R1 and informed R1 that they have to checked R1's bruises but R1 refused with aggressive and combative behavior and that's when S9 called the paramedics for R1. Interview with S9 indicated that S9 was working at the facility on 09/08/2023 and S9 reported that S9 assisted S8 to transfer R1 back on R1's motorized wheelchair and they both observed bruises on R1 and informed R1 that they have to checked R1's bruises but R1 refused with aggressive and combative behavior. Interviews with S8 and S9 revealed that due to R1's observed bruises, *Continuation in LIC9099C***

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

DATE: 12/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/30/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 56-AS-20231122161045
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: CORONA RESIDENTIAL CARE CENTER LLC
FACILITY NUMBER: 336427235
VISIT DATE: 09/22/2024
NARRATIVE
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they called for medical emergency for appropriate medical care. During the facility visit on 11/30/2023 and 07/30/2024, LPA Brown observed staffs at the facility are adequately supervising their residents as LPA Brown noted that staffs are checking on their residents on their scheduled rounds of at least every two (2) hours.

The third allegation indicates that staff did not provide assistance to resident in a timely manner. During the investigation, LPA Brown did not find evidence to corroborate the allegation. Interviews with seven (7) of seven residents indicated that all staffs at the facility are assisting them in a timely manner. Interviews with seven (7) of seven (7) residents revealed that staffs at the facility are always ready to help them and it takes about five (5) minutes for a staff to arrive and the longest would be ten (10) minutes. LPA Brown unable to interview three (3) residents as R1 passed away on 12/29/2023, and R7 and R9 were sleeping. Interviews with nine (9) of nine (9) staffs indicated that they all provide assistance to all the residents at the facility in a timely manner. Seven (7) of seven (7) staffs interviewed reported that it usually takes them three (3) to five minutes to assist a resident. Five (5) of six (6) staffs interviewed revealed that there's no incident that happened at the facility that a staff did not provide assistance to R1 in a timely manner. Interview with S8 indicated that when S8 saw R1 fell from R1's motorized wheelchair on 09/08/2023, S8 immediately attended to R1 and contacted S9 for assistance to help R1 transfer back to R1's wheelchair. S8 stated that they observed bruises on R1 and informed R1 that they have to check R1's bruises but R1 refused their assistance with aggressive and combative behavior and that's when S9 called the paramedics for R1. Interview with S9 confirmed that S9 helped S8 transfer back R1 to R1' s motorized wheelchair and both S8 and S9 reported to LPA Brown that R1 refused their help to check and assess R1's bruises and S8 and S9 both stated that R1 exhibited aggressive and combative behavior on 09/08/2023. Interview with S8 and S9 revealed that they both observed that R1 sustained bruises on R1's fall, and they promptly contacted medical emergency for appropriate medical treatment to R1. During the facility visit on 07/30/2024, LPA Brown observed that staffs at the facility are assisting residents at the facility in a timely manner as it took them two (2) to three (3) minutes to arrive at a resident room when pressing residents pull cord.

Based on the evidence, the allegations that Licensee does not ensure that facility grounds are free from hazards to residents in care (Allegation #1), Staff did not adequately supervise resident in care resulting in resident sustaining an injury while in care (Allegation #2), and Staff did not provide assistance to resident in a timely manner (Allegation #3) are UNSUBSTANTIATED. A finding that the complaint is UNSUBSTANTIATED means although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated at this time.



An exit interview was conducted where this report, LIC9099 was discussed and provided to Assistant Administrator Mary Gonzalez.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 12/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/30/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 7
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
11/22/2023 and conducted by Evaluator Melody Brown
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20231122161045

FACILITY NAME:CORONA RESIDENTIAL CARE CENTER LLCFACILITY NUMBER:
336427235
ADMINISTRATOR:AHARON STRIKSFACILITY TYPE:
740
ADDRESS:1400 CIRCLE CITY DRTELEPHONE:
(951) 735-0252
CITY:CORONASTATE: CAZIP CODE:
92879
CAPACITY:125CENSUS: 84DATE:
09/22/2024
UNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Medical Technician/Caregiver Marco NavarroTIME COMPLETED:
10:30 AM
ALLEGATION(S):
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Staff do not ensure that resident is administered their medication(s) as prescribed while in care.
INVESTIGATION FINDINGS:
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On 09/22/2024 at 09:15 AM, Licensing Program Analyst (LPA) Melody Brown made an unannounced visit to the facility to deliver the findings of the above allegation. LPA Brown explained the purpose of the visit to a staff. Staff contacted Assistant Administrator Mary Gonzalez and informed of the visit. LPA Brown explained the purpose of the visit to Medical Technician (MedTech)/Caregiver Marco Navarro. The investigation consisted of file review, interviews with staffs 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 Staff do not ensure that resident is administered their medication(s) as prescribed while in care. LPA Brown obtained evidence to corroborate the allegation above. Staff #1 (S1) and two (2) Medical Technician (MedTech) staffs reported that residents medications are administered as prescribed by their physician’s. However, per Resident #1 (R1) electronic Medication Administration Records (MAR) review, LPA Brown noted that R1 medications were not administered ***Continuation in LIC9099C***
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 09/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2024
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 7
Control Number 56-AS-20231122161045
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: CORONA RESIDENTIAL CARE CENTER LLC
FACILITY NUMBER: 336427235
VISIT DATE: 09/22/2024
NARRATIVE
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as prescribed by R1 physician as evidenced of R1's 11/2023 electronic MAR showed multiple medications were not given to R1 on multiple days as LPA Brown observed blank entry on R1's MAR and staffs at the facility did not indicate why R1's medications were not given per R1's physician's directions. In addition, per R1's MAR review, LPA Brown noted seven (7) of R1's medications were recorded by a staff as unknown. In addition, during the facility visit on 09/16/2024, LPAs Brown and Howell-Small inquired to Staff #1 why R1's 11/2023 electronic MAR have multiple days blank entries per R1's eMAR Review and why seven (7) medication were recorded by a staff as unknown, and S1 informed LPAs Brown and Howell-Small that S1 will review R1's 11/2023 electronic MAR to provide the requested information. On 09/18/2024, LPA Brown received an email message from S1 with new R1 11/2023 MAR attachment and indicated that the attached R1's electronic MAR was given to previous LPA of the facility and no other explanation provided. LPA Brown reviewed R1's new 11/2023 electronic MAR received, the observed multiple days with blank entries from R1's 11/2023 electronic MAR received on 07/30/2024 now has handwritten entries of staffs initials. LPA Brown noted that the facility was utilizing electronic MAR on R1's 11/2023 MAR and on 09/18/2024, R1's 11/2023 electronic MAR was observed with staffs handwritten initials. Also, the reported R1's seven (7) medications were still recorded by a staff as unknown in new R1's 11/2023 MAR received on 09/18/2024. Furthermore, during the visit today, Staff #3 (S3) reported to LPA Brown that the blank entries on R1's 11/2023 electronic MAR's unacceptable and also added that the handwritten initials in R1's 11/2023 electronic MAR is not S3's handwriting.

Based on LPA Brown’s observations and records review, the preponderance of evidence standard has been met, and therefore the above allegation of Staff do not ensure that resident is administered their medication(s) as prescribed while 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.

Furthermore, LPA Brown reviewed compliance history and observed that the facility was issued the same deficiency 87465 Incidental Medical and Dental Care (a)(4) for not assisting residents with self administered medications on 04/15/2024. Civil Penalty was assessed for repeat violation within a 12-month period with the amount of $250.00 per citation and will continue to be assessed of $100.00 per day per citation until corrected. ***Continuation on LIC9099C***
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 09/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 7
Control Number 56-AS-20231122161045
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: CORONA RESIDENTIAL CARE CENTER LLC
FACILITY NUMBER: 336427235
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/22/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
09/23/2024
Section Cited
CCR
87465(a)(4)
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87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall... (4) The licensee shall assist residents with self-administered medications... This requirement is not met as evidenced by:Based on interview and records review,
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Licensee has agreed to conduct Medication Training on CCR 87465(a)(4) to all staffs dispensing medications to residents and submit proof to LPA Brown on Plan of Correction (POC) due date.
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 the Licensee did not comply with the section cited above by not ensuring that staff are providing the required medication assistance to Resident #1 (R1) as prescribed by R1 physician which poses an immediate 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: Melody Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 09/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2024
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 56-AS-20231122161045
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: CORONA RESIDENTIAL CARE CENTER LLC
FACILITY NUMBER: 336427235
VISIT DATE: 09/22/2024
NARRATIVE
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An exit interview was conducted with MedTech/Caregiver Marco Navarro where a copy of this report, (LIC 9099) along with LIC9099D, LIC421FC and Appeal Rights were discussed and provided.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 09/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2024
LIC9099 (FAS) - (06/04)
Page: 7 of 7