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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 361880863
Report Date: 08/20/2025
Date Signed: 08/20/2025 01:59:38 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 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
12/10/2021 and conducted by Evaluator Paola Guerrero
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20211210113613
FACILITY NAME:ALOHA RESIDENTIAL CAREFACILITY NUMBER:
361880863
ADMINISTRATOR:KHAN, ASMATFACILITY TYPE:
740
ADDRESS:7476 BUNGALOW WAYTELEPHONE:
(951) 675-7763
CITY:RANCHO CUCAMONGASTATE: CAZIP CODE:
91739
CAPACITY:6CENSUS: 6DATE:
08/20/2025
UNANNOUNCEDTIME BEGAN:
12:58 PM
MET WITH:Yaritza Jarquen-CaregiverTIME COMPLETED:
02:13 PM
ALLEGATION(S):
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Neglect/lack of care and supervision resulting in resident to sustain multiple pressure injuries.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Paola Guerrero conducted an unannounced visit to the facility to deliver complaint investigation findings. After introducing and identifying self, LPA met with facility caregiver Yaritza Jarquen to discuss the findings.

On December 10, 2021, the Department received a complaint with allegation of personal rights violation of neglect of R1. The Department investigation consisted of review of facility and medical records,observations, and interviews with pertinent individuals. Investigation revealed that on November 25, 2021, R1 was admitted to the hospital due to change of condition. Medical records indicate that upon admission, R1 had the following conditions including but not limited to: small blister to the left flank, small skin tear to the right scapular area, stage 3 decubitus ulcer over the buttocks, blister to the left lateral heel and right medial knee. Additional conditions present on admission include Stage 2 pressure injury to right heel, Stage 2 pressure injury to left heel, and Stage 2 pressure injury to left ear. At the hospital, R1 required surgery for debridement of infected sacral ulcer (pressure injuries).

Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Paola Guerrero
LICENSING EVALUATOR SIGNATURE:

DATE: 08/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2025
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-20211210113613
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: ALOHA RESIDENTIAL CARE
FACILITY NUMBER: 361880863
VISIT DATE: 08/20/2025
NARRATIVE
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Facility records reviewed did not indicate continuous observation nor care being provided for all conditions observed at hospital admission, in addition, staff interviews did not reveal consistent observation and care of these multiple conditions. In some cases, facility staff reported during interviews that they were unaware of one or more of R1’s wounds (pressure injuries).

R1 was admitted to the facility on or around October 9, 2021. Records indicate that R1 was to be provided basic services at a minimum to include continuous care and supervision, observation for changes in physical, mental, emotional, and social functioning; and notification to R1 family, physician, and other appropriate person/agency of R1's needs. In addition, R1 was to be provided with assistance with personal activities of daily living including dressing, eating, toileting, bathing, grooming, mobility tasks. More specifically, R1 is described as non-ambulatory and requires a wheelchair for mobility, help with transferring in and out of bed, and incontinent care to be provided. When R1 was admitted to the facility, no pressure injuries were indicated in physician report nor pre-placement appraisal.

From time period prior to and following admission, R1 was receiving home health services. The services included nurse visits, first documented in records to have occurred on November 16, 2021. During that visit, home health records indicate that closed wounds were assessed on buttocks. Plans were indicated for cleaning of area and rotating area every 2-4 hours to prevent pressure sore from developing.

During a subsequent home health visit on November 23, 2021, two wounds were observed. One wound was identified in home health records as an unstageable pressure ulcer. According to records, facility staff were made aware of wound care plan and treatment, including pressure sore prevention, and instruction to have R1 repositioned as frequently as possible every 2-4 hours. Facility staff were also to put pillows under R1 back and not to cover coccyx/sacral area and to monitor potential pressure sore areas such as heels, elbows, shoulders, knees, back, Etc. As noted upon hospital admission on November 25, 2021 (two days later), R1 was observed with multiple pressure injuries to areas such as flank, scapular area, both heels, left ear, knee, and buttocks.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Paola Guerrero
LICENSING EVALUATOR SIGNATURE:

DATE: 08/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 18-AS-20211210113613
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: ALOHA RESIDENTIAL CARE
FACILITY NUMBER: 361880863
VISIT DATE: 08/20/2025
NARRATIVE
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Based on the investigation, there is preponderance of evidence to support that facility staff neglected R1. Specifically, it was found that from at least October 9, 2021, until November 25, 2021, facility staff did not ensure care and supervision to meet R1 needs. Per facility records, R1 was to be provided continuous care and supervision as well as assistance with activities of daily living, including mobility and incontinent care. However, during the time when R1 resided at facility, R1 sustained multiple pressure injuries. Facility records and staff interviews support that facility staff were not continuously providing care and supervision to R1 to meet their needs. More specifically, R1 was observed on November 23, 2021, with two wounds, but two days later, was hospitalized and observed to have multiple pressure injuries.
Allegation of neglect/lack of care and supervision resulting in R1 sustaining multiple pressure injuries is substantiated.
A substantiated finding means that the allegation is valid because the preponderance of evidence standard has been met.
In addition, this violation posed an immediate Health and Safety risk to resident(s) in care. An Immediate Civil Penalty of $500 is being assessed. The licensee was also informed that a civil penalty may be assessed based on Health and Safety Code § 1569.49.

An exit interview was conducted where this report, LIC9099D, LIC421IM, and appeal rights were discussed and provided to Facility Caregiver Yaritza Jarquen at the end of the visit.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Paola Guerrero
LICENSING EVALUATOR SIGNATURE:

DATE: 08/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 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
12/10/2021 and conducted by Evaluator Paola Guerrero
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20211210113613

FACILITY NAME:ALOHA RESIDENTIAL CAREFACILITY NUMBER:
361880863
ADMINISTRATOR:KHAN, ASMATFACILITY TYPE:
740
ADDRESS:7476 BUNGALOW WAYTELEPHONE:
(951) 675-7763
CITY:RANCHO CUCAMONGASTATE: CAZIP CODE:
91739
CAPACITY:6CENSUS: 6DATE:
08/20/2025
UNANNOUNCEDTIME BEGAN:
12:58 PM
MET WITH:Yaritza Jarquen- CaregiverTIME COMPLETED:
02:13 PM
ALLEGATION(S):
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Staff refused to return resident's personal belongings
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Paola Guerrero conducted an unannounced visit to deliver findings on the allegations listed above. LPA met with Facility Caregiver Yaritza Jarquen and explained the purpose of the visit. The investigation consisted of interviews, observations, and review of records.

First allegation: Staff refused to return resident's personal belongings. Regarding the allegation stated above LPA conducted an interview with Staff #1 who informed LPA that R#1 personal belongings were released and given to R#1 family. In addition, S#1 informed LPA that R#1 medical equipment was still at the facility. S#1 informed LPA that R#1 medical equipment was ordered and belonged to Sunrise Medical, and that R#1 medical equipment was going to be picked-up by Sunrise Medical being the fact that the equipment belonged to Sunrise Medical and not R#1. During review of records LPA observed that: Hoyer lift, hospital bed, and wheelchair, was returned back to DME/Sunrise. Based on corroborating evidence obtained during the course of the investigation, LPA has determined that the above allegation is Unsubstantiated.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Paola Guerrero
LICENSING EVALUATOR SIGNATURE:

DATE: 08/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2025
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 6
Control Number 18-AS-20211210113613
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: ALOHA RESIDENTIAL CARE
FACILITY NUMBER: 361880863
VISIT DATE: 08/20/2025
NARRATIVE
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Unsubstantiated: meaning that 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 (LIC 9099) was discussed, and a copy was provided to Facility Caregiver Yaritza Jarquen at the end of the visit.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Paola Guerrero
LICENSING EVALUATOR SIGNATURE:

DATE: 08/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 18-AS-20211210113613
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: ALOHA RESIDENTIAL CARE
FACILITY NUMBER: 361880863
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/20/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/21/2025
Section Cited
CCR
87468.2(a)(4)
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Additional Personal Rights of Residents in Privately Operated Facilities....
(a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: ....(4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs.
This requirement is not met as evidenced by:
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The Licensee has agreed to read over the regulation "Additional Personal Rights of Residents" and provide a training touching basis on Resident care, supervision, and services that meet resident’s individual needs. POC will be provided to LPA by POC dated 8/21/2025.
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Based on interviews, and record review, the Licensee did not ensure that R1 received care and supervision to meet R1 needs. On November 25, 2021, R1 was admitted to the hospital with multiple pressure injuries (wounds), which poses an immediate Health, Safety, or Personal Rights risk to resident(s) 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: Paola Guerrero
LICENSING EVALUATOR SIGNATURE:

DATE: 08/20/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2025
LIC9099 (FAS) - (06/04)
Page: 6 of 6