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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331800424
Report Date: 01/30/2026
Date Signed: 01/30/2026 02:38:28 PM

Substantiated


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
08/08/2025 and conducted by Evaluator Raquel Hernandez
COMPLAINT CONTROL NUMBER: 56-AS-20250808100431
FACILITY NAME:EASTVALE SENIOR HOME CARE IIFACILITY NUMBER:
331800424
ADMINISTRATOR:BADILLA, ADELAIDAFACILITY TYPE:
740
ADDRESS:14318 PINTAIL LOOPTELEPHONE:
(951) 220-7354
CITY:EASTVALESTATE: CAZIP CODE:
92880
CAPACITY:6CENSUS: 6DATE:
01/30/2026
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Administrator Arjan Marlo BanezTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Due to staff neglect, resident sustained a pressure injury
Staff retained a resident with a prohibited health condition
Staff did not notify authorized representative of change in condition
Unqualified staff treating a pressure injury
Questionable death
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Raquel Hernandez conducted an unannounced visit to deliver findings on the allegation listed above. LPA met with Administrator Arjan Marlo Banez and explained the purpose of the visit.

On August 8, 2025, the Department received a complaint with allegation of personal rights violation resulting in R1 sustaining a pressure injury. The Department investigation consisted of review of facility and other records, observations, and interviews with pertinent individuals.

Per facility records, R1 was admitted to the facility at the end of January 2025. According to physician report completed around this time, R1 did not have pressure injuries. However, records did indicate that R1 has history of skin condition or breakdown.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Raquel Hernandez
LICENSING EVALUATOR SIGNATURE:

DATE: 01/30/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2026
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 7
Control Number 56-AS-20250808100431
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: EASTVALE SENIOR HOME CARE II
FACILITY NUMBER: 331800424
VISIT DATE: 01/30/2026
NARRATIVE
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In addition, records indicated that R1 did not have capacity for self-care in areas including bathing, dressing, incontinent care, and medication administration. R1 was non-ambulatory, used wheelchair, and needed help with transferring, moving about facility. Also, R1 needed special observation/night supervision. Based upon further records review, there was no written record of the care R1 would be receiving in the facility. The written record of care would have included how facility would provide care to meet R1 care and observation needs.

During the investigation, it was revealed that on or around June 13, 2025, R1 was observed with reddened area on tailbone (sacral area). Several facility staff, including administrator, acknowledged awareness of reddened area on R1 on June 13th, 2025. It is not indicated how long the reddened area was observed prior to June 13th , 2025. From around June 13th, 2025, until July 16, 2025, the reddened area on R1 sacral was not assessed by physician nor skilled medical professional. Facility staff acknowledged that during this time, the area was being treated with ointment, not authorized by physician or skilled medical professional. Responsible party of R1 was made aware of the “worsening” of the reddened area on July 12th, 2025. This prompted the responsible party, not facility staff, to make contact for medical assessment. When the area was assessed by medical professional on July 16th, 2025, it was found that R1 had an unstageable pressure injury.

Per Title 22 regulations, "Pressure Injury" means localized damage to the skin and/or soft tissue under the skin that is usually over a bony part of the body or related to a medical or other device. This damage can appear as intact skin or an open ulcer and may be painful. It occurs as a result of intense and/or prolonged pressure on the affected part of the body or pressure combined with shear (an action or stress that causes internal parts of the body to become deformed). Based on appearance and severity, the damage to tissue is a Stage 1, 2, 3, or 4 pressure injury.”

Unstageable pressure injury, according to the Mayo Clinic, is “an unstageable pressure ulcer (or bedsore) is a full-thickness skin and tissue loss where the wound bed is obscured by dead, yellow, brown, or black tissue (slough or eschar), preventing healthcare providers from determining the true depth and extent of the damage until that tissue is removed. It's considered a serious injury (Stage 3 or 4)………”.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Raquel Hernandez
LICENSING EVALUATOR SIGNATURE:

DATE: 01/30/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 56-AS-20250808100431
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: EASTVALE SENIOR HOME CARE II
FACILITY NUMBER: 331800424
VISIT DATE: 01/30/2026
NARRATIVE
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Based upon Department investigation, the allegation that due to staff neglect, R1 sustained an unstageable pressure injury is substantiated. Facility staff did not ensure that R1 received the care needed and identified in facility records. R1 was admitted to facility with no pressure injuries. R1 had history of skin condition or breakdown. However, no written record of care was documented to include how facility would provide care and observation to meet R1 needs. Prior to or around June 13th, 2025, R1 developed reddened area on sacral area, but facility staff neglected to obtain appropriate assistance for care. The area continued to worsen and then R1 was diagnosed with unstageable pressure injury to the area on July 16th, 2025.

A deficiency is being issued per California Code of Regulations, Title 22. 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 the Administrator Arjan Marlo Banez.

Additionally, On August 08, 2025. The department received a complaint in regards to facility staff retained a resident with a prohibited health condition. Through interviews, it was revealed R1 had an unstageable pressure injury, which is a prohibited health condition in Title 22 Regulations. The department observed the facility staff did not attempt to relocate or notify department of prohibited health condition. The finding is substantiated A deficiency is being issued per California Code of Regulations, Title 22.

Furthermore, on August 08, 2025 the department received a complaint regarding facility staff not notifying authorized representative of change in condition. Interviews revealed R1’s responsible party was made aware of pressure injury on 07/12/2025, however, facility staff stated R1’s responsible party was made aware of pressure injury on 06/13/2025. The department determined there is not sufficient evidence to support R1’s responsible party was informed of change in condition of R1. A deficiency is being issued per California Code of Regulations, Title 22.

Moreover, on August 08, 2025 the department received an additional complaint regarding untrained staff treating a pressure injury. Interviews revealed that facility staff confirmed to treating R1’s reddened area/stage wound with ointment that was not ordered from hospital or physician. Additionally, interviews and observations disclosed no documentation of turning or repositioning R1. The finding is substantiated. A deficiency is being issued per California Code of Regulations, Title 22.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Raquel Hernandez
LICENSING EVALUATOR SIGNATURE:

DATE: 01/30/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 7
Control Number 56-AS-20250808100431
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: EASTVALE SENIOR HOME CARE II
FACILITY NUMBER: 331800424
VISIT DATE: 01/30/2026
NARRATIVE
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On August 8, 2025, the Department received a complaint with allegation of personal rights violation which contributed to R1 death/questionable death. The Department investigation consisted of review of facility and other records, observations, and interviews with pertinent individuals.

R1 relocated from facility on July 18th , 2025, and subsequently passed away on August 1st , 2025. The sacral pressure injury was identified as condition contributing to R1 death. Based on the investigation, there is preponderance of evidence to support that facility staff neglected R1. Specifically, it was found that from around June 13th 2025, until July 16th, 2025, staff did not provide R1 with care and services to meet their needs. During this time, R1 sustained an unstageable pressure injury and subsequently passed away. The allegation that facility staff neglect contributed to R1 death/questionable death 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 the Administrator Arjan Marlo Banez.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Raquel Hernandez
LICENSING EVALUATOR SIGNATURE:

DATE: 01/30/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2026
LIC9099 (FAS) - (06/04)
Page: 4 of 7
Control Number 56-AS-20250808100431
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: EASTVALE SENIOR HOME CARE II
FACILITY NUMBER: 331800424
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/30/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/02/2026
Section Cited
CCR
87468.2(a)(4)
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87468.2 Additional Personal Rights of Residents in Privately Operate Facilities (a) In addition to the rights listed... (4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient...
This requirement was not met as evidenced by:
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Licensee stated to read over regulation with facility staff and not allow facility staff to care for any residents with prohibited health conditions.
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Based upon review of facility and other records, observations, and interviews with pertinent individuals, licensee failed to ensure that R1 was provided with care, supervision, and services required. As a result, R1 sustained an unstageable pressure injury while at facility. This violation posed an immediate health and saftey risk to residents in care.
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Type A
02/02/2026
Section Cited
CCR
87615(a)(1)
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87615 Prohibited Health Conditions (a) ) Persons who require health services for or have a health condition...(1) Stage 3 and 4 pressure injuries.
This requirement was not met as evidenced by:
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Licensee stated to read over regulation and to not accept residents with prohibited health care conditions without care by licensed care professional and/or notifying licensing department. POC will be cleared.
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Based on observations and interviews, the licensee did not comply with section cited above by not ensuring that R1 was relocated due to pressure injury and or notified licensing department, which poses an immediate health, saftey and 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: Efren Malagon
LICENSING EVALUATOR NAME: Raquel Hernandez
LICENSING EVALUATOR SIGNATURE:

DATE: 01/30/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2026
LIC9099 (FAS) - (06/04)
Page: 5 of 7
Control Number 56-AS-20250808100431
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: EASTVALE SENIOR HOME CARE II
FACILITY NUMBER: 331800424
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/30/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/02/2026
Section Cited
CCR
87468.2(a)(4)
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87468.2 Additional Personal Rights of Residents in Privately Operate Facilities (a) In addition to the rights listed... (4) To care, supervision...
This requirement was not met as evidenced by:
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Licensee stated to not admit any future residents with prohibited health conditions unless waiver is submitted to licensing department and care is provided by a licensed care professional.
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From around June 13th 2025, until July 16th, 2025, R1 was not provided care and services to meet their needs. Records revealed that R1 needed care and assistance in ADLs, including incontinent care, as well as observation with history of skin condition or breakdown. Under the care of facility staff, R1 sustained an unstageable pressure injury, and subsequently passed away. This posed an immediate risk to residents in care.
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Type A
02/02/2026
Section Cited
CCR
87466
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87466 Observation of the Resident: The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs...
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Licensee stated to read over regulation with facility staff on Observation of the Resident. POC will be cleared.
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Based on observation and interviews, the licensee did not comply with section cited above by not ensuring R1's responsible party was notified of change of condition in R1, which poses an immediate health, saftey, and personal rights risk to persons 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: Raquel Hernandez
LICENSING EVALUATOR SIGNATURE:

DATE: 01/30/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2026
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 56-AS-20250808100431
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: EASTVALE SENIOR HOME CARE II
FACILITY NUMBER: 331800424
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/30/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/02/2026
Section Cited
CCR
87411(d)(5)
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87411 Personnel Requirements - General (d) All personnel shall be given on the job training or have related experience in the job assigned to them... (5) Knowledge necessary in order to recognize early signs of illness and the need for professional help.
This requirement is not met as evidenced by:
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Licensee stated to read over regulation with facility staff and acknowledged having only appropriate skilled professionals care for residents with prohibited/restricted health care conditions. POC will be cleared.
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Based on observation and interviews, the licensee did not comply with section cited above by not ensuring R1 received care from an appropriate skilled professional and having staff care for R1 instead, which poses an immediate health, saftey, and 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: Efren Malagon
LICENSING EVALUATOR NAME: Raquel Hernandez
LICENSING EVALUATOR SIGNATURE:

DATE: 01/30/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2026
LIC9099 (FAS) - (06/04)
Page: 7 of 7