<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 335530171
Report Date: 12/26/2024
Date Signed: 12/26/2024 02:14:29 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 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
12/24/2024 and conducted by Evaluator Mary Rico
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20241224140916
FACILITY NAME:WILDOMAR SENIOR ASSISTED LIVINGFACILITY NUMBER:
335530171
ADMINISTRATOR:YOUSEFIAN, ROSEFACILITY TYPE:
740
ADDRESS:32365 SOUTH PASADENA STTELEPHONE:
(323) 902-6000
CITY:WILDOMARSTATE: CAZIP CODE:
92595
CAPACITY:200CENSUS: 113DATE:
12/26/2024
UNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Administartor- Karen RoperTIME COMPLETED:
02:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not ensure resident’s call pendant was in good repair.
Staff did not assist residents with care needs in a timely manner.
Licensee did not maintain facility in good repair.





INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Mary Rico conducted an unannounced visit to investigate and deliver findings on the allegations listed above. LPA met with Administrator Karen Roper and explained the purpose of the visit. The investigation consisted of staff interviews, resident interviews, and record review.

For the allegation, Staff did not ensure resident’s call pendant was in good repair.

During residents’ interviews, 9 out of the 10 residents stated their pendants are working. 1 out of the 10 residents was unable to collaborate on the allegation listed above. During staff interviews 6 out of the 6 staff stated resident’s pendants are working.

During facility tour, LPA Rico tested residents’ pendants, all pendants observed to be working.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Mary Rico
LICENSING EVALUATOR SIGNATURE:

DATE: 12/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/26/2024
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-20241224140916
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: WILDOMAR SENIOR ASSISTED LIVING
FACILITY NUMBER: 335530171
VISIT DATE: 12/26/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
For the allegation, Staff did not assist residents with care needs in a timely manner.

During resident interviews, 8 out of the 10 residents stated staff provide assistance in a timely manner. 2 out of the 10 residents stated they are independent and do not require care assistance. During staff interviews 6 out of the 6 staff stated they assist residents in a timely manner.

For the allegation, Licensee did not maintain facility in good repair.

During resident interviews, 10 out of the 10 residents stated the facility is in good repair. During staff interviews, 6 out of the 6 staff stated that residents sinks are working, and the facility is in good repair. In addition, 6 out of the 6 staff stated maintenance staff will fix any repairs needed.

During facility tour, LPA observed residents sinks to be working, and observed documentation of facility's repair log.

Based on the evidence found during the investigation, the three (3) allegations listed above are 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 and provided to Administrator Karen Roper.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Mary Rico
LICENSING EVALUATOR SIGNATURE:

DATE: 12/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/26/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2