361880660-9-23-2025-56-AS-NBRN-DTCV9D-20260421161411

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 361880660
Report Date: 05/06/2025
Date Signed: 09/23/2025 05:00:57 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
02/01/2024 and conducted by Evaluator Lavette Farlow

COMPLAINT CONTROL NUMBER: 56-AS-20240201124236

FACILITY NAME:	RIALTO ASSISTED LIVING		FACILITY NUMBER:	361880660
ADMINISTRATOR:	KYONG SUK LEE		FACILITY TYPE:	740
ADDRESS:	1441 S RIVERSIDE AVE		TELEPHONE:	(909) 877-2340
CITY:	RIALTO	STATE: CA	ZIP CODE:	92376
CAPACITY:	94	CENSUS: 60	DATE:	05/06/2025
		UNANNOUNCED	TIME BEGAN:	09:10 AM
MET WITH:	Beverly Robertson, Office Assistant, and Darcy Poua, Med-Tech		TIME COMPLETED:	02:45 PM

ALLEGATION(S):

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Due to lack of supervision, resident AWOL'd from facility and was hit by a car and died
Staff are not reporting falls to community care licensing

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) La Vette Farlow made an unannounced visit to the facility for the purpose of concluding the complaint allegations and deliver the findings to the above mentioned complaint. LPA met with Staff, and was granted access into the facility. LPA talked to the Beverly Robertson, Office Assistant, and Darcy Poua, Med-Tech Supervisor and informed them about the purpose of the visit. LPA later met with Administrator, Tae Kim. The investigation consisted of observations, interviews with staff and records review.

It is alleged that due to lack of supervision, resident AWOL'd from the facility and was hit by a car and died. Staff interviews confirmed that the resident was known to frequently walk in and out of the facility, often visiting nearby stores or the surrounding community, and had consistently returned without incident in the past. File review and staff interviews confirmed that the resident did not have a diagnosis of dementia and was able to leave the facility unassisted. Interviews with R1 family members confirmed that R1 was able to leave the facility unattended.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Lavette Farlow
LICENSING EVALUATOR SIGNATURE:	DATE: 05/06/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2025

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 56-AS-20240201124236

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: RIALTO ASSISTED LIVING	FACILITY NUMBER: 361880660
	VISIT DATE: 05/06/2025

NARRATIVE

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LPA interviewed 11 staff, and 11 out of 11 staff stated they never observed any behavior from R1 that would indicate, R1 needed more supervision. 11 out of 11 staff did agree that R1 would walk a lot but would return to the facility. Based on observations, interviews and record review on the above allegation is Unsubstantiated.

It is alleged that Staff are not reporting falls to community care licensing. Records review and interviews revealed that the facility is reporting falls to CCL. LPA interviewed 11 out of 11 staff and 11 of the staff reported that the facility procedure is to report any falls or any incident that requires reporting to Med-Tech and they will complete the SIR. Interviews revealed that staff never heard or experienced management telling them not to report falls. LPA interview 4 out of 4 staff stating Med-Tech are required to complete SIR and they submit them to the Administrator. LPA observed care notes and SIR on record and accessible to CCL. Based on information obtained during interview and file review, the allegation is unsubstantiated.

Based on observations, interviews and record review, the allegations, due to lack of supervision, resident AWOL’ d from facility and was hit by a car and died and staff are not reporting falls to community care licensing are Unsubstantiated. A finding of 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. An exit interview was conducted where this report was discussed and provided to Administrator, Tae Kim.

SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Lavette Farlow
LICENSING EVALUATOR SIGNATURE:	DATE: 05/06/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2025

LIC9099 (FAS) - (06/04)

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