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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 335530171
Report Date: 02/13/2025
Date Signed: 02/13/2025 02:50:24 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/17/2024 and conducted by Evaluator Melody Brown
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20241217130651
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: 110DATE:
02/13/2025
UNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Executive Director Karen RoperTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Licensee is charging resident in excess of the rate allowed for Basic Services for SSI recipient.
INVESTIGATION FINDINGS:
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On 02/13/2025 at 01:15 PM, Licensing Program Analyst (LPA) Melody Brown arrived unannounced at the facility to deliver findings for the allegation listed above. LPA Brown was greeted and granted entry by a staff and Executive Director (ED) Karen Roper was contacted and informed of the visit. LPA Brown explained the purpose of the visit to ED Roper. The investigation consisted of interviews and a review of pertinent documentation.

The investigation was conducted by LPA Melody Brown. The investigation consisted of observation and interviews with relevant parties. The allegation indicates that Licensee is charging resident in excess of the rate allowed for Basic Services for SSI recipient. During the investigation, LPA Brown did not find evidence to corroborate the allegation. Interview with Resident #1 (R1) indicated that R1 is receiving Social Security Benefits as R1 indicated that R1 was working before as a part-time office staff and worked long enough and paid Social Security taxes. Per records review, R1 was receiving more than the Non-Medical Out-of Home Care (NMOHC) payment standard for Individuals in a Licensed Facility that receives ***Cont. in LIC9099C***
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 02/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/13/2025
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 2
Control Number 56-AS-20241217130651
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME: WILDOMAR SENIOR ASSISTED LIVING
FACILITY NUMBER: 335530171
VISIT DATE: 02/13/2025
NARRATIVE
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Social Security Income (SSI) and State Supplementary Payment (SSP). Moreover, interview with R1 family member confirmed that R1 was receiving more than the amount dispensed for SSI and SSP recipient as R1 family member provided a copy of Social Security Benefits that R1 was receiving from Social Security. In addition, R1 family member informed LPA Brown that R1 has other income source that R1 utilized to pay for total required fees at the facility.

Based on the evidence, the allegation that Licensee is charging resident in excess of the rate allowed for Basic Services for SSI recipient is UNSUBSTANTIATED. A finding that the complaint is UNSUBSTANTIATED means although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated at this time.

An exit interview was conducted and a copy of this report, LIC9099 was discussed and provided to ED Karen Roper.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 02/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/13/2025
LIC9099 (FAS) - (06/04)
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