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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331880902
Report Date: 09/16/2026
Date Signed: 09/16/2026 05:38:01 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE 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
04/07/2026 and conducted by Evaluator Ahliah Sharp
COMPLAINT CONTROL NUMBER: 18-AS-20260407151225
FACILITY NAME:BUENA VISTA ASSISTED LIVINGFACILITY NUMBER:
331880902
ADMINISTRATOR:ICAMEN, ROBYNFACILITY TYPE:
740
ADDRESS:1393 S. BUENA VISTA ST.TELEPHONE:
(951) 658-5160
CITY:HEMETSTATE: CAZIP CODE:
92543
CAPACITY:74CENSUS: 52DATE:
09/16/2026
UNANNOUNCEDTIME BEGAN:
05:00 PM
MET WITH:Robyn Icamen, Executive DirectorTIME COMPLETED:
05:35 PM
ALLEGATION(S):
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Facility staff did not ensure to provide a safe environment for residents in care.
Facility staff denied resident(s) to be able to attend their medical appointment.
Facility staff did not treat residents with dignity and respect.
Facility staff do not maintain a comfortable temperature for residents.
INVESTIGATION FINDINGS:
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On 09/16/2026 Licensing Program Analyst (LPA), Ahliah Sharp, conducted an unannounced visit to the facility to deliver findings regarding the allegations above. During the investigation, LPA Sharp conducted an inspection of the facility, interviewed staff and residents, reviewed facility records and made necessary observations pertaining to the allegations listed above.
On 04/07/2026, Community Care Licensing (CCL) received a complaint alleging staff did not ensure to provide a safe environment for residents in care, staff denied resident(s) to be able to attend their medical appointments, staff did not treat residents with dignity and respect and staff did not maintain a comfortable temperature for residents.
Regarding the allegation of staff failing to ensure a safe environment for residents, information obtained from interviews with staff denied the information.

Continued on LIC 9099C...
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Jacob Garber
LICENSING EVALUATOR NAME: Ahliah Sharp
LICENSING EVALUATOR SIGNATURE:

DATE: 08/24/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2026
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 4
Control Number 18-AS-20260407151225
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: BUENA VISTA ASSISTED LIVING
FACILITY NUMBER: 331880902
VISIT DATE: 09/16/2026
NARRATIVE
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Continued from LIC9099...

Three (3) of the six (6) staff interviewed mentioned an increase in memory care residents being admitted, and a change overall in the residents that are being allowed to be admitted, noting that although this has happened, they do not feel the staff are failing to keep the residents safe. Executive Director Robyn Icamen noted that one of the main priorities is, and has always been, the safety of the residents in care. The remaining three (3) were completely unaware of any concerns surrounding the safety of residents. Information obtained from interviews with residents denied the information and confirmed the information obtained from staff. Nine (9) residents were interviewed, out of the nine (9) interviews, five (5) residents mentioned the increase of memory care patients, two (2) of those five (5) noted the memory care resident’s inability to remember their correct room from time to time. Two (2) residents did indicate a ‘fear’ that they attributed specifically to the residents but neither of the two noted staff as the problem in failing to keep them safe. The remaining two (2) interviewed denied any concerns at all. Out of the initial five (5) residents, although they expressed concern for the residents, they did not specifically state this caused them to believe they were not safe or that staff has somehow failed to keep them safe. It was noted more of a frustration than an actual concern for their safety.

Based on the information obtained from interviews with staff and residents, the allegation that staff failed to provide a safe environment for residents has been deemed UNSUBSTANTIATED. Unsubstantiated means although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.

Regarding the allegation of staff denying residents to be able to attend their medical appointments, information obtained from interviews with staff denied the information. Out of the six (6) staff interviewed, six (6) out of six (6) denied the information. They denied having any knowledge of any residents ever being denied access to medical appointments. They denied any knowledge of any residents notifying them of being denied access to medical appointments. Information obtained from interviews with residents denied the information. Out of nine (9) interviews conducted, all nine denied any issues with staff denying residents the ability to attend their medical appointments.

Continued on LIC9099C...(2)

SUPERVISORS NAME: Jacob Garber
LICENSING EVALUATOR NAME: Ahliah Sharp
LICENSING EVALUATOR SIGNATURE:

DATE: 09/16/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 18-AS-20260407151225
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: BUENA VISTA ASSISTED LIVING
FACILITY NUMBER: 331880902
VISIT DATE: 09/16/2026
NARRATIVE
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Continued from LIC9099C...(2)

Three (3) of the nine stated they have appointments and a family member makes all their arrangements and coordinates their transportation. One (1) said they do not really have any appointments, one (1) said the appointments they have are generally done in house and the doctor comes to the facility, one (1) said they had one problem with insurance failing to coordinate with their transportation services to bring them to their appointment but acknowledged this was an insurance issue and not an error of the facility itself. The remaining three (3) denied any issues or problems with appointments. There were no documented issues noted in any files reviewed.

Based on the information obtained from interviews with staff and residents, and record review, the allegation that staff denied residents to be able to attend their medical appointments, has been deemed UNSUBSTANTIATED. Unsubstantiated means that although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.

Regarding the allegation that staff did not treat residents with dignity and respect, the information obtained from staff denied the information. According to the staff interviews, none of them reported any information to support the allegation. They were asked if any resident had reported any information about being mistreated by staff, and they denied having any knowledge to support the allegation. Information obtained from the interviews with residents denied the information and corroborated the information from the staff. Out of the nine (9) interviews conducted, seven (7) residents denied feeling like they were not being treated with dignity and respect. One (1) resident stated they have never felt any form of disrespect and shared that they came from a place that did not treat them so well, and they were so grateful that their experience is so much better here than it was at the old facility. The remaining one (1) resident stated that although they feel like they have not been treated poorly, they reported, “Some of the staff do not act like they really want to be here, they act like it is just a job.” They still did not mention feelings of disrespect.

Based on the information obtained from interviews with staff and residents, the allegation that staff did not treat residents with dignity and respect has been deemed UNSUBSTANTIATED. Unsubstantiated means that although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.

Continued on LIC9099C...(3)

SUPERVISORS NAME: Jacob Garber
LICENSING EVALUATOR NAME: Ahliah Sharp
LICENSING EVALUATOR SIGNATURE:

DATE: 09/16/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 18-AS-20260407151225
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: BUENA VISTA ASSISTED LIVING
FACILITY NUMBER: 331880902
VISIT DATE: 09/16/2026
NARRATIVE
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Continued from LIC9099...(3)

Regarding the allegation that staff do not maintain a comfortable temperature for residents, the information obtained from staff denied the information. According to staff interviews, out of the six (6) interviews, two (2) acknowledged the difficulties with keeping the temperature satisfactorily for so many residents having different needs and wants as it relates to body temperature. They reported being mindful of this and still doing their best to be accommodating to residents if they say it is too hot or too cold. The controls are maintained in the main office. Information obtained from Executive Director Robyn Icamen, if or when residents state they are hot, they will lower the temperature, the same attention is given if they say they are too cold. According to residents’ interviews, one (1) resident mentioned knowing that they are cold often, so they take it upon themselves to make sure to dress in layers, they noted that it is not fair to have the facility to keep it warm just for them. Seven (7) residents denied any issues with the temperature and the remaining one (1) acknowledge that Robyn is good at keeping up with the different temperature requests. Based on observation of LPA Sharp when at the facility conducting the investigation. LPA made several visits throughout the course of this investigation (4/6;4/9/; 5/12; 6/3; 6/15), LPA observed the thermostats and all of them were well within the Department regulation at those times.

Based on the information obtained from interviews with staff and residents, and observation, the allegation that staff do not maintain a comfortable temperature for residents has been deemed UNSUBSTANTIATED. Unsubstantiated means that although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.

No deficiencies were issued and no immediate health and safety concerns were observed at time of visit. A copy of the reports LIC9099, and all LIC9099C's were reviewed and provided to Executive Director Icamen.

SUPERVISORS NAME: Jacob Garber
LICENSING EVALUATOR NAME: Ahliah Sharp
LICENSING EVALUATOR SIGNATURE:

DATE: 09/16/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2026
LIC9099 (FAS) - (06/04)
Page: 4 of 4