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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331881251
Report Date: 04/08/2026
Date Signed: 04/08/2026 02:18:29 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
10/16/2024 and conducted by Evaluator Beena Singh
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20241016133606
FACILITY NAME:WESTHILLS VILLA GARDENSFACILITY NUMBER:
331881251
ADMINISTRATOR:ALMA ESPINALFACILITY TYPE:
740
ADDRESS:5466 WEST WILSON ST.TELEPHONE:
(951) 849-7521
CITY:BANNINGSTATE: CAZIP CODE:
92220
CAPACITY:30CENSUS: 18DATE:
04/08/2026
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Facility Administrator-Thelma MontebanTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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9
Resident sustained bedsore (stage 4 - unstageable) due to staff neglect.
INVESTIGATION FINDINGS:
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On 04/08/2026, Licensing Program Analyst (LPA) Beena Singh conducted an unannounced visit to initiate and deliver findings on the allegation listed above. LPA was greeted by Facility administrator and granted entry to the facility and explained the purpose of the visit. The investigation consisted of interviews, observations, and review of records.

First Allegation: Resident sustained bedsore (stage 4 - unstageable) due to staff neglect.
Licensing Program Analyst (LPA) Singh conducted a comprehensive review of facility records, confirming that Resident #1 (R#1) was receiving hospice and home health services specifically for wound care, repositioning, and assistance with activities of daily living (ADL). Additionally, all eight residents interviewed expressed complete satisfaction with their care, specifically noting that staff are always available for daily assistance and ensure that bedridden residents are regularly repositioned and helped with personal needs. LPA Singh observed that the facility was clean and sanitary throughout the visit. Residents were seen resting comfortably in their beds or participating in seated exercises with the active assistance of staff members.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Beena Singh
LICENSING EVALUATOR SIGNATURE:

DATE: 04/08/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2026
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-20241016133606
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: WESTHILLS VILLA GARDENS
FACILITY NUMBER: 331881251
VISIT DATE: 04/08/2026
NARRATIVE
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Furthermore, eight (8) out of eight(8) residents verified that bedridden individuals are regularly repositioned and receive diligent assistance with toileting and other essential care needs, indicating that the facility is maintaining appropriate standards of supervision and physical support.

Based on the evidence found during the investigation, the allegation listed Resident sustained bedsore (stage 4 - unstageable) due to staff neglect is deemed UNSUBSTANTIATED. A finding that the complaints are UNSUBSTANTIATED means although the allegation may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. During today’s visit, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations.

An exit interview was conducted, and this report (LIC9099) was discussed, signed and provided to Facility Administrator- Thelma Monteban, facility representative.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Beena Singh
LICENSING EVALUATOR SIGNATURE:

DATE: 04/08/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 2