Inspection Reports for River‘s Edge

An unannounced annual inspection was conducted to evaluate compliance with licensing requirements at the facility.

No deficiencies were cited during the inspection. The facility was found to be in compliance with all applicable regulations including food safety, medication administration, resident safety, and staff background clearances.

An unannounced case management deficiencies inspection was conducted to address deficiencies observed during a complaint investigation regarding resident R1.

The facility failed to provide timely medical assistance for R1's worsening bilateral thigh wounds and did not implement interventions to prevent further deterioration. Additionally, the facility did not meet requirements for basic services, including proper toileting assistance and re-evaluation of R1's condition, resulting in serious bodily injuries and immediate health and safety risks.

The inspection was triggered by a complaint investigation concerning resident R1's bilateral thigh wounds that were worsening and not properly addressed by the facility.

An unannounced case management inspection was conducted to observe and photograph a resident bedroom.

No deficiencies were cited during the inspection per California Code of Regulations, Title 22.

An unannounced annual inspection was conducted by Licensing Program Analyst Kimberly Viarella to evaluate compliance with regulatory requirements at the facility.

The inspection found the facility generally in compliance with medication administration, resident room safety, and fire extinguisher maintenance. However, deficiencies were cited related to expired pantry food items and improper storage of a refrigerated item, posing potential health and safety risks.

The inspection was an unannounced complaint investigation visit triggered by complaints received on 2024-07-25 regarding food storage temperatures and kitchen equipment repair.

Two allegations were substantiated: staff did not ensure perishable food was stored at proper temperatures due to a malfunctioning refrigerator replaced on 2024-09-30, and staff did not ensure kitchen equipment was in good repair, including a broken deli slicer. Other allegations related to contaminated food disposal, resident communication, personal hygiene, and infection control were found to be unsubstantiated.

The complaint investigation was substantiated for two allegations: improper food storage temperatures and kitchen equipment not in good repair. The refrigerator was not maintaining required temperatures and was replaced after 61 days. The deli slicer was also broken and repaired. Other allegations regarding contaminated food disposal, resident communication, personal hygiene, and infection control were unsubstantiated.

The inspection was an unannounced complaint investigation visit triggered by allegations that the licensee does not ensure the facility is in good repair and that staff do not respond to resident requests for assistance in a timely manner.

The investigation found that although the allegations may have happened or be valid, there was not a preponderance of evidence to prove the alleged violations did or did not occur. The elevator had multiple breakdowns, causing delays in resident assistance, but the facility implemented measures such as staff assistance and alternative dining arrangements. Staff response times varied but were generally timely. No deficiencies were cited.

The complaint was unsubstantiated. Allegations included facility disrepair, elevator breakdowns, delayed staff response to resident calls, and safety concerns. Investigations included interviews with residents and staff, review of maintenance logs, and observations. The elevator broke down 12 times with some prolonged outages. Staff and external services assisted residents during outages. Response times ranged from immediate to up to 45 minutes depending on staffing and time period. No fire drills had been conducted according to residents. The roof leak allegation was found unfounded.

The inspection was an unannounced complaint investigation visit conducted to address multiple allegations received on 2024-03-14 regarding inappropriate resident placement decisions, coercion of a dementia resident into signing documents, billing a resident for two rooms simultaneously, and denial of dining room choice.

All allegations were investigated through staff interviews, document reviews, and resident file assessments. The Department concluded that all allegations were either unfounded or unsubstantiated, with no evidence supporting claims of inappropriate decision-making, coercion, improper billing, or denial of dining room choice.

The complaint investigation addressed four main allegations: 1) Facility director made inappropriate decisions for a resident's placement at another facility where a staff member later became director; 2) Staff coerced a dementia resident into signing documents; 3) Staff billed a resident for two rooms at the same time; 4) Staff did not allow a resident to dine in the dining room of their choice. All allegations were found to be unfounded or unsubstantiated based on interviews, document reviews, and resident care assessments.

An unannounced complaint investigation was conducted regarding an allegation that staff did not prevent the facility roof from leaking.

The investigation found that roofing work was actively being conducted by Sonray and Paragon Construction crews with no resident rooms affected. The allegation was deemed unfounded as no deficiencies were observed or cited.

The complaint was investigated and found to be unfounded, meaning the allegation was false or without reasonable basis. No deficiencies were cited.

The visit was an unannounced case management inspection conducted as part of an investigation into complaint control number 27-AS-20231121160532 regarding deficiencies identified during the complaint investigation.

The investigation revealed that resident R1 was not served meals from 11/19/23 to 11/21/23 at breakfast, lunch, and dinner, as confirmed by interviews and review of meal logs. A deficiency was cited for failure to ensure R1 received at least three meals per day during that period.

The visit was conducted in response to complaint control number 27-AS-20231121160532. Deficiencies were substantiated related to failure to provide meals to resident R1 as alleged.

An unannounced complaint investigation was conducted in response to allegations that staff were not addressing vermin in the facility and not keeping the facility free from odors from incontinence.

The investigation found no preponderance of evidence to substantiate the allegations. Pest control services were documented as ongoing and effective, and no odors from incontinence were observed during multiple visits.

The complaint investigation was unsubstantiated based on facility observations, staff interviews, and record reviews. Allegations regarding vermin and odors from incontinence were both found to be unsubstantiated.

An unannounced complaint investigation was conducted following allegations that staff left a resident soiled for an extended period, did not meet the resident's care needs timely, did not clean the resident's room adequately, and did not maintain a comfortable room temperature.

The investigation substantiated the allegations that a resident was left unattended for 2-3 days, resulting in inadequate care, supervision, and environmental conditions. Deficiencies were cited related to basic services, maintenance of comfortable temperature, cleanliness, and incontinent care, posing immediate or potential health and safety risks.

The complaint investigation was substantiated. The allegations included staff leaving a resident soiled for an extended period, failure to meet care needs timely, inadequate room cleaning, and failure to maintain comfortable room temperature. The resident was left unattended for about 2-3 days. Immediate civil penalties of $500 and $250 (repeat violation) were assessed.

The visit was an unannounced case management inspection conducted as part of an investigation into complaint control number 27-AS-20231206120154, addressing identified deficiencies related to vermin issues in the facility.

The inspection found vermin droppings in two locked apartments (#312 and #316) that were not accessible to residents but posed potential health and safety risks. Although ongoing pest control services were documented, the licensee failed to ensure these apartments were cleaned and free of vermin droppings.

Investigation was triggered by complaint control number 27-AS-20231206120154. The deficiency was substantiated as vermin droppings were observed, and an immediate civil penalty of $250 was assessed due to repeat violation.

An unannounced complaint investigation was conducted in response to allegations that the facility elevator was in disrepair and that facility staff did not provide adequate food service to residents in care.

Based on interviews, observation, and record review, the allegations were found to be unsubstantiated. The elevator was repaired promptly and was operational during the investigation, and food service was adequately provided to residents during the elevator outage.

The complaint investigation was unsubstantiated, meaning there was not a preponderance of evidence to prove the alleged violations occurred.

An unannounced complaint investigation was conducted in response to an allegation that the facility is in disrepair.

The investigation substantiated the allegation that a fire door near the laundry room and memory care entrance was in disrepair, not functioning or closing properly, posing an immediate health, safety, and personal rights risk to residents.

The complaint was substantiated based on observations and interviews confirming the facility is in disrepair, specifically a malfunctioning fire door that did not close properly during a fire alarm test.

An unannounced complaint investigation visit was conducted in response to a complaint received on 2023-09-11 alleging the facility failed to repair a broken elevator and that staff failed to serve meals in a timely manner.

The investigation found no preponderance of evidence to substantiate the allegations. The elevator was inoperable from September 7 to 15 due to a bad circuit board, but the facility acted promptly to remedy the issue. Staff and resident interviews indicated meals were provided in a timely manner despite elevator outages.

The complaint was unsubstantiated. The elevator repair delay was due to waiting for replacement circuit boards. Staff and resident interviews confirmed timely meal service. The same elevator had a prior outage in May 2023, which was also unsubstantiated in a previous complaint.

An unannounced annual continuation inspection was conducted to ensure compliance with Title 22 regulations and to review the physical plant of the facility.

The inspection found no deficiencies. The Licensing Program Analyst toured the facility, reviewed fire inspection reports, medication administration records, staff and resident files, and inspected the kitchen and fire extinguisher tags.

An unannounced annual inspection was conducted to ensure compliance with Title 22 regulations, including inspection of the physical plant and review of facility operations.

The inspection identified several deficiencies including missing first aid certificates for nine out of ten employees, improper kitchen freezer and refrigerator temperatures, and lack of implementation of gluten-free diet plans for residents. The inspection was not completed due to time constraints and will continue at a later date.

Unannounced complaint investigation visit conducted to investigate allegations regarding elevator disrepair, accessibility of doctor appointments and planned activities, staff response to call buttons, and accuracy of food menu.

The investigation found conflicting statements and insufficient evidence to substantiate the allegations. Elevator issues were confirmed but promptly addressed, residents had access to appointments and activities with staff assistance, call response times averaged 8 minutes within training objectives, and food service provided multiple meal options meeting nutritional needs. No deficiencies were cited.

The complaint included allegations of elevator disrepair, inaccessible doctor appointments and planned activities, delayed staff response to call buttons, and inaccurate food menus. The investigation concluded these allegations were unsubstantiated due to lack of preponderance of evidence.

The inspection was an unannounced complaint investigation visit triggered by allegations received on 2023-02-01 regarding staff neglect, hygiene needs, assistance with ADLs, room cleanliness, feeding, and medication administration.

The investigation found the allegation of staff neglect causing an unstageable pressure injury to be unsubstantiated, with evidence showing the injury existed prior to the resident's return. Allegations regarding unmet hygiene needs, lack of assistance with ADLs, unclean rooms, feeding, and medication administration were found to be unsubstantiated or unfounded based on interviews and record reviews.

The complaint investigation was unsubstantiated. The allegations included staff neglect causing a pressure injury, failure to meet hygiene needs, failure to assist with ADLs, failure to maintain clean rooms, failure to feed residents, and improper medication administration. The investigation concluded there was insufficient evidence to support these allegations and found them unsubstantiated or unfounded.

The visit was an unannounced complaint investigation triggered by allegations that staff do not answer resident's call button in a timely manner and that there was insufficient staffing to meet residents' needs.

The allegation regarding delayed response to resident call buttons was substantiated, with records showing approximately 16 instances in June 2023 where staff responded after 25 minutes. The allegation of insufficient staffing was found to be unsubstantiated based on resident interviews and evidence reviewed.

The complaint investigation was substantiated for the allegation that staff did not answer resident's call button in a timely manner. The allegation of insufficient staffing was unsubstantiated. The investigation was conducted by Licensing Program Analyst Tung Truong, with findings delivered on 07/19/2023.

An unannounced complaint investigation was conducted due to an allegation that staff administered the wrong medication to a resident.

The investigation substantiated that the facility did not administer the correct medication to resident R1, as another resident's medications were given to R1 by staff. This posed an immediate health and safety risk to residents in care.

The complaint was substantiated based on interviews and records reviewed. The allegation involved medication error where staff administered the wrong medication to a resident.

The inspection was an unannounced visit to investigate complaints received on 01/27/2023 regarding the facility's adherence to the Admission Agreement and proper notification of resident rate increases.

The investigation substantiated that the facility failed to properly monitor resident R1 as required by the Admission Agreement, resulting in elopement, and did not provide proper written notice of rate increases to the resident and representative. Another allegation regarding cleanliness of a resident's room was found to be unfounded.

The complaint investigation was substantiated for failure to adhere to the Admission Agreement and failure to provide proper notification of rate increases. The allegation regarding unclean resident room was found to be unfounded.

An unannounced Case Management Inspection was conducted to address the current administrator status at the facility, following the departure of the former administrator and pending appointment of a new administrator.

The facility is currently conducting interviews for a permanent new administrator, with the Regional Director temporarily assuming administrator responsibilities. No deficiencies were cited during the inspection.

An unannounced complaint investigation was conducted in response to an allegation that staff were not administering medication to a resident.

The investigation found the allegation to be unfounded after reviewing medication records and interviews, confirming that the facility followed regulations and medication was administered as prescribed. No deficiencies were cited.

The complaint alleging staff not administering medication to a resident was investigated and determined to be unfounded, meaning the allegation was false or without reasonable basis.

An unannounced complaint investigation visit was conducted to investigate an allegation that a resident wandered from the facility due to lack of supervision by staff.

The investigation found that a resident (R1) eloped from the facility on 2023-01-24 and the facility was unaware of the resident's whereabouts at that time. The resident was determined by a physician to be unable to leave the facility unassisted. The allegation was substantiated and deficiencies were cited.

The complaint was substantiated based on interviews and record reviews. Civil penalties of $500 were assessed for immediate violations related to the resident wandering due to lack of supervision.

An unannounced complaint investigation was conducted regarding allegations that staff were mismanaging residents' medications.

The investigation substantiated that Resident 1 missed two days of a daily prescribed medication due to staff oversight, posing an immediate health and safety risk. Deficiencies were cited related to failure to assist residents with self-administered medications.

The complaint alleging staff mismanagement of resident medications was substantiated based on interview and record review. Resident 1 missed two days of medication due to staff oversight.

An unannounced complaint investigation was conducted regarding multiple allegations including facility infestation, resident hygiene, missed meals, and timely staff response to resident needs.

The investigation found no evidence of bed bugs or neglect related to resident hygiene, missed meals, or timely care. The facility has a rat problem due to location but is actively managing it. Allegations were determined to be unsubstantiated or unfounded.

The complaint investigation was triggered by allegations of bed bugs, residents not showered, residents left in soiled diapers and dirty clothes, rats in the facility, missed meals, and untimely staff response. The allegations were found to be unsubstantiated or unfounded after interviews, observations, and record reviews.

An unannounced complaint investigation was conducted regarding the allegation that facility staff is not providing the necessary documents to the insurance company.

The investigation found that the facility is providing the insurance documents to Long Term Care. A staff member made a mistake filling out the documents, but it was corrected promptly. The allegation was determined to be without a reasonable basis and was found to be unfounded.

The complaint alleged that facility staff were not providing necessary documents to the insurance company. The allegation was investigated and determined to be unfounded.

An unannounced complaint investigation was conducted regarding allegations that staff did not seek medical attention in a timely manner, did not provide adequate food service, did not administer medications timely, did not respond to call buttons timely, and resident's laundry needs were not being met.

The investigation found some allegations unsubstantiated, including delayed medical attention and inadequate food service due to multiple outbreaks. However, allegations that staff delayed medication administration, delayed response to call buttons, and failed to meet laundry needs were substantiated, posing potential or immediate health and safety risks to residents.

The complaint investigation was unannounced and initiated based on a complaint received on 08/08/2022. The investigation was conducted by Licensing Program Analyst Christopher Hopkins-Clarke. Some allegations were found unsubstantiated due to lack of preponderance of evidence, while others were substantiated based on interviews and record reviews.

The inspection was an unannounced required 1 year annual inspection conducted to evaluate the facility's compliance with health and safety regulations.

The facility was observed to be clean, odor-free, and in good repair with compliant water temperatures, food supplies, fire safety equipment, and medication storage. However, deficiencies were cited related to personnel training, specifically expired First Aid certifications in 4 out of 5 staff files reviewed.

An unannounced complaint investigation was conducted regarding allegations that residents were not receiving medications on time during the night, the facility was not addressing a rat and mice problem, residents were leaving the building unsupervised, and there was insufficient staff to meet resident needs.

The investigation found that residents were receiving their medications on time, the rodent issue was confined to the garbage area outside the facility and was being addressed with a contract, residents were not leaving unsupervised due to security measures, and staff responded to call buttons within a reasonable time. The allegations were unsubstantiated due to lack of preponderance of evidence.

The complaint investigation was unsubstantiated. Allegations included medication timing, rodent problems, resident supervision, and staffing levels. Interviews, record reviews, and observations did not support the allegations.

An unannounced complaint investigation was conducted regarding allegations including that the facility elevator was in disrepair.

The investigation found that the elevator was in and out of service, which was substantiated. The elevator was repaired and observed to be functioning properly, but the failure to ensure proper elevator function posed a potential health and safety risk to residents.

The complaint investigation was substantiated based on preponderance of evidence standards regarding the elevator being in disrepair.

The visit was an unannounced case management inspection conducted on May 19, 2022, regarding a deficiency from a complaint investigation originally investigated on January 21, 2022.

The facility was found deficient for not ensuring Resident 1 was able to get out of a recliner after a caregiver raised the footrest, which led to the resident falling out of the recliner. This posed an immediate health and safety risk to residents in care.

The visit was related to a deficiency from a complaint investigation conducted on 01/21/2022. The deficiency was substantiated based on video evidence showing the resident fell due to inability to lower the recliner footrest.

Unannounced complaint investigation visit conducted due to multiple allegations including failure to follow resident's care plan, inadequate staff training, resident injuries, and insufficient staffing.

The investigation found most allegations unsubstantiated due to lack of preponderance of evidence, except for the allegation that a resident was left unattended on the floor overnight, which was substantiated based on video footage and interviews. The facility was cited for failure to provide adequate care and supervision.

The complaint investigation was triggered by multiple allegations including failure to follow care plan, inadequate staff training, resident fractures, refusal to accept resident back after hospital visit, failure to notify representative timely, unclean room, resident unkempt, pressure injury, insufficient staffing, and failure to request exception for recliner use. Most allegations were unsubstantiated except for the resident left unattended on the floor overnight, which was substantiated.

The visit was an unannounced case management inspection regarding three incident reports submitted to the Department on 10/05/2021 and 10/07/2021.

The Executive Director reported that an internal investigation concluded with video evidence identifying a staff member from a staffing agency as responsible. The Sheriff's Department has taken over the investigation. Staff training on theft prevention was conducted, and residents are offered to list valuables upon admission. No deficiencies were cited during this visit.

The visit was triggered by three incident reports related to theft. The internal investigation identified a staff member as the culprit, and the Sheriff's Department is handling the case. The complaint investigation is ongoing with no deficiencies cited.

The inspection was an unannounced complaint investigation visit conducted in response to a complaint received on 09/03/2021 alleging that staff did not assist residents with their toileting and shower needs in a timely manner.

The investigation substantiated the allegation that staff did not assist a resident with their toileting needs in a timely manner, with the resident waiting approximately forty-five minutes for assistance. The allegation regarding staff not assisting residents with showers was found to be unsubstantiated based on interviews and facility logs.

The complaint was substantiated for the allegation that staff did not assist a resident with toileting needs in a timely manner. The allegation regarding assistance with showers was unsubstantiated.

The visit was an unannounced case management visit regarding three incident reports submitted to the Department involving missing money and stolen property reported by residents.

The Executive Director had taken proper steps including reporting to Licensing and Ombudsman, filing police reports, conducting interviews, internal investigations, staff retraining, and resident council meetings. No deficiencies were cited as a result of the visit.

The visit was an unannounced case management inspection conducted due to an incident reported on 09/07/2021 involving a missing coin purse from a resident's apartment.

The administrator had taken all proper steps with reporting, investigating, and retraining staff. No deficiencies were cited as a result of the visit.

The incident involved a missing coin purse from resident R1's apartment on 09/07/2021. The complaint was investigated with interviews and review of reports, and no deficiencies were found.

The visit was an unannounced annual inspection conducted by Licensing Program Analyst Tung Truong to evaluate compliance with Title 22 regulations at the facility.

The facility was found to be clean, odor-free, and in good repair with proper furnishings, sanitary bathrooms, adequate food supply, and secure medication storage. No deficiencies were observed during this visit, and the facility had implemented a Covid-19 mitigation plan with routine symptom screening and hygiene procedures.

The visit was an unannounced complaint investigation triggered by a complaint received on 2021-04-12 regarding the facility elevator being in disrepair.

The investigation found that the elevator was in disrepair for an hour, which posed a potential risk to the health, safety, and personal rights of residents. The complaint was substantiated based on interviews and document review.

The complaint was substantiated based on the preponderance of evidence standard. The elevator was confirmed to be in disrepair for an hour, posing a potential risk to residents.

The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2020-12-21 regarding insufficient staffing to meet residents' needs and inadequate food services.

The allegation of insufficient staffing was found to be unsubstantiated due to lack of preponderance of evidence, although some residents reported waiting up to 30 minutes for care. The allegation of inadequate food services was found to be unfounded after review of menus, facility documents, and tele-visit inspection showing adequate food variety and options.

The complaint investigation was unannounced and involved allegations of insufficient staffing and inadequate food services. The staffing allegation was unsubstantiated, meaning there was insufficient evidence to prove the violation occurred. The food services allegation was unfounded, meaning it was false or without reasonable basis.

The inspection was an unannounced complaint investigation visit triggered by complaints received on 12/28/2020 regarding failure to meet residents' needs, pest issues, inadequate food services, trash disposal, and staff training.

The investigation substantiated that an incontinent resident was left unattended on the toilet for approximately 40 minutes during a shift change, posing an immediate health risk. Other allegations including pest presence, inadequate food services, trash disposal, and staff training were found to be unsubstantiated or unfounded.

The complaint investigation was substantiated for failure to meet residents' needs related to continence care. The allegation regarding pests was unsubstantiated. Allegations about inadequate food services, trash disposal, and staff training were unfounded.

The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2020-07-30 regarding staff not providing timely assistance to residents.

The investigation included interviews, document reviews, and a virtual tour. The department found the allegation of staff not providing timely assistance unsubstantiated, meaning there was insufficient evidence to prove the violation. Other allegations regarding call button response, room cleanliness, and pressure sores were found to be unfounded.

The complaint alleged staff not providing assistance to residents in a timely manner, staff not responding to residents' call buttons, residents' room carpets being dirty, and a resident sustaining a pressure sore while in care. The findings were unsubstantiated or unfounded based on interviews, documentation, and virtual tour evidence.