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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374603683
Report Date: 05/08/2025
Date Signed: 05/08/2025 12:31:10 PM

Substantiated


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
05/01/2025 and conducted by Evaluator Janira Arreola
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20250501160911
FACILITY NAME:BREEZE HILL CAREFACILITY NUMBER:
374603683
ADMINISTRATOR:SMILJA MILOSAVLJEVICFACILITY TYPE:
740
ADDRESS:799 MARSOPA DRIVETELEPHONE:
(760) 631-0267
CITY:VISTASTATE: CAZIP CODE:
92081
CAPACITY:6CENSUS: 5DATE:
05/08/2025
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Staff, Eva BartolazoTIME COMPLETED:
12:35 PM
ALLEGATION(S):
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Staff did not provide proper supervision to resident in care resulting in multiple falls
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Janira Arreola conducted an unannouned visit in order to investigation the allegations listed above. LPA met with Staff, Eva Bartolazo and spoke with Administrator Smilja Milosavljevic over the phone who were informed of the purpose of the visit. LPA conducted interviews, observations and records review.

It was alleged "Staff did not provide proper supervision to resident in care resulting in multiple falls", regarding Resident #1 (R1) who experiences falls while at the facility due to lack of supervision at night. LPA attempted to conduct interview with R1, however R1 was not available for interview.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE:

DATE: 05/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2025
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 5
Control Number 18-AS-20250501160911
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: BREEZE HILL CARE
FACILITY NUMBER: 374603683
VISIT DATE: 05/08/2025
NARRATIVE
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LPA conducted (3) staff interviews which revealed R1 experienced wandering behaviors and experienced a fall occurring after 3 am when R1 got up at night to go to the restroom. All (3) staff interviewed confirmed staff are on call at night and there is no awake staff. Records review revealed physician's report identifying R1 with Condition #1 (C1). There was no readmission appraisal or plan of care on file for R1.

According to California Code of Regulations (CCR) Title 22, person's identified with C1 in facilities with (16) residents or less require at least (1) awake staff at night. Therefore, based on interviews and records review the allegation is substantiated. The preponderance of the evidence standard has been met and CCR Title 22 regulation is being cited on the attached LIC9099-D. An exit interview was conducted where this and attached reports including appeal rights were reviewed and provided.
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE:

DATE: 05/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 5
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
05/01/2025 and conducted by Evaluator Janira Arreola
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20250501160911

FACILITY NAME:BREEZE HILL CAREFACILITY NUMBER:
374603683
ADMINISTRATOR:SMILJA MILOSAVLJEVICFACILITY TYPE:
740
ADDRESS:799 MARSOPA DRIVETELEPHONE:
(760) 631-0267
CITY:VISTASTATE: CAZIP CODE:
92081
CAPACITY:6CENSUS: DATE:
05/08/2025
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Staff Eva BartolazoTIME COMPLETED:
12:35 PM
ALLEGATION(S):
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Staff sedated resident in care
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Janira Arreola conducted an unannouned visit in order to investigation the allegations listed above. LPA met with Staff, Eva Bartolazo and spoke with Administrator Smilja Milosavljevic over the phone who were informed of the purpose of the visit. LPA conducted interviews, and records review.

It was alleged "Staff sedated resident in care" regarding R1 who was given Medication #1 (M1) incorrectly to keep R1 in bed at night. LPA attempted to conduct interview with R1, however R1 was not available for interview. Interview with (2) facility staff revealed R1 was taking M1 as needed for wandering behavior.
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE:

DATE: 05/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 18-AS-20250501160911
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: BREEZE HILL CARE
FACILITY NUMBER: 374603683
VISIT DATE: 05/08/2025
NARRATIVE
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Records review revealed medication order for R1's physician stating R1 was prescribed M1 with instructions: "Please give extra dose of M1 at night if patient restless or wanders."

Therefore based on records review and interviews the allegation that M1 was being used to sedate R1 in bed and was given incorrectly is unfounded. The allegation was false, could not have happened and/or is without a reasonable basis. An exit interview was conducted, and a copy of this report was provided.
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE:

DATE: 05/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Citations on this Visit Report are Under Appeal!

Control Number 18-AS-20250501160911
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: BREEZE HILL CARE
FACILITY NUMBER: 374603683
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/08/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Under Appeal
Type A
05/09/2025
Section Cited
CCR
87705(b)(2)
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Care of Persons with Dementia(b) Licensees shall be responsible for the following: (2) For facilities with fewer than 16 residents, ensuring there is at least one night staff person awake and on duty if any resident with dementia is determined through...observation, to require awake night supervision.
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The licensee agreed to submit an updated LIC500 showing staff coverage at night by the POC due date.
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This requirment was not met as evidenced by: Based on interview and record review R1 had Condition #1 and the facility was not providing night supervision with awake staff. Based on interview staff were aware R1 had wandering behaviors. This poses an immediate health saftey or personal rights risk to residents 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: Anthony Perez
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE:

DATE: 05/08/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5