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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 336425524
Report Date: 08/30/2026
Date Signed: 08/30/2026 04:24:50 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
01/08/2026 and conducted by Evaluator Edith Conchas
COMPLAINT CONTROL NUMBER: 56-AS-20260108163849
FACILITY NAME:EMORY TERRACEFACILITY NUMBER:
336425524
ADMINISTRATOR:RAYMOND CHUFACILITY TYPE:
740
ADDRESS:34 EMORY AVENUETELEPHONE:
(951) 402-3697
CITY:BEAUMONTSTATE: CAZIP CODE:
92223
CAPACITY:6CENSUS: 5DATE:
08/30/2026
UNANNOUNCEDTIME BEGAN:
03:40 PM
MET WITH:Caregiver Tiffany ColantonioTIME COMPLETED:
04:40 PM
ALLEGATION(S):
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Staff did not ensure that resident was adequately fed.
Staff did not ensure that resident received sufficient fluids to prevent dehydration.
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPA) E.Conchas conducted an unnannounced visit for the purpose of delivering findings on the allegations stated above. LPA met with caregiver Tiffany Colantonio and explained the purpose of the visit.

On 01/08/2026, the Department received a complaint regarding the allegations stated above. The Department’s investigation consisted of interviews, review of hospice documentation, hospital records, and facility records.

Allegation Staff did not ensure that resident was adequately fed.
Record review indicates that on 01/02/2026, R1 was admitted to the hospital for altered level of consciousness. Witness (W1) reported that on 01/04/2026, Witness (W2) expressed concerns of potential neglect due to R1 appearing cachectic and clinically dehydrated.

Contiue to LIC9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Edith Conchas
LICENSING EVALUATOR SIGNATURE:

DATE: 08/30/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2026
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 2
Control Number 56-AS-20260108163849
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: EMORY TERRACE
FACILITY NUMBER: 336425524
VISIT DATE: 08/30/2026
NARRATIVE
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On 01/05/2026, W2 met with W3 at the hospital. A speech therapist evaluated R1 and determined R1 was unlikely to consume sufficient nutrition or fluids orally to sustain life. The dietitian expressed concern regarding R1’s nutritional status. W2 informed W3 that a placement of a feeding tube would be necessary to consume nutrition or fluids to sustain life; however, W3 declined artificial nutrition, choosing to continue comfort care under hospice services. R1 was discharged from the hospital and returned to the facility on 01/07/2026.
Review of hospice documentation revealed that as early as 11/04/2025, R1 was unable to consume nutritional food or fluids and was placed on aspiration precautions, pureed diet, and thickened liquids. Documentation from 11/11/2025 indicated muscle wasting and meal refusals, with intake limited to small sips of water. A hospice assessment dated 11/20/2025 documented cachexia, prominent bony features, and extremely limited intake. Hospice notes dated 01/01/2026 indicated continued poor intake despite caregiver efforts. R1 was discharged from hospice on 01/02/2026 due to hospitalization and readmitted on 01/07/2026.
Based on record review and interviews, R1’s nutritional decline was consistent with terminal medical conditions and end of life status under hospice care—not due to lack of care or neglect by the facility. This allegation is UNSUBSTANTIATED.

Allegation Staff did not ensure that resident received sufficient fluids to prevent dehydration.
Interview with S1 confirmed R1 had been receiving hospice services since early November of 2025. S1 stated that staff made multiple attempts to offer fluids and documented refusals after the third attempt, consistent with facility practice. Hospice assessments dated 11/04/2025, 11/11/2025, and 11/20/2025 documented clinical dehydration, cachexia, and thickened liquid/aspiration precautions. Hospice notes dated 01/01/2026 indicated continued poor fluid intake despite caregiver encouragement. Evidence reflects R1’s poor fluid intake was directly related to medical decline associated with hospice care, including limited tolerance for fluids, difficulty swallowing, and end stage cachexia. There is no evidence that insufficient care or lack of intervention by the facility contributed to R1’s condition. This allegation is UNSUBSTANTIATED.

Based on interviews, record review, hospice documentation, and hospital records, the Department finds that both allegations are UNSUBSTANTIATED: meaning that although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur.

An exit interview was conducted where this report was discussed and a copy was provided to the care staff Tiffany at the conclusion of the visit.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Edith Conchas
LICENSING EVALUATOR SIGNATURE:

DATE: 08/30/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2026
LIC9099 (FAS) - (06/04)
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