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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 335530171
Report Date: 03/13/2025
Date Signed: 03/13/2025 04:39:18 PM

Substantiated


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
03/11/2025 and conducted by Evaluator Melody Brown
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20250311092303
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: 115DATE:
03/13/2025
UNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Executive Director Karen RoperTIME COMPLETED:
04:45 PM
ALLEGATION(S):
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Staff did not ensure light was fixed properly in resident bathroom.
Staff did not ensure the aluminum threshold ramp was fixed/replaced to meet the residents needs.
INVESTIGATION FINDINGS:
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On 03/13/2025 at 01:15 PM, Licensing Program Analyst (LPA) Melody Brown arrived unannounced at the facility commence and deliver the findings of a complaint investigation. LPA was greeted and granted entrance by a staff and met with Executive Director (ED) Karen Roper. LPA Brown explained the purpose of the visit with ED Roper. The investigation consisted of observation and interviews with relevant parties.

First allegation: Staff did not ensure light was fixed properly in a resident bathroom.The investigation was conducted by LPA Melody Brown which consisted of observation and interviews with relevant parties. The first allegation indicates staff did not ensure light was fixed properly in a resident bathroom. During the investigation, LPA Brown was able to obtain sufficient evidence to corroborate the allegation. LPA Brown interviewed Resident # 1 (R1) and R1 indicated that the light in R1's bathroom at the center of the ceiling will not turn on and the busted one (1) bulb on top of R1's bathroom mirror and that makes it hard for R1 due to R1's falling eyesight. Interview with Staff #3 (S3) indicated that the light at the center of R1's bathroom ceiling was busted, and will not turn on. ***Continuation in LIC9099C***
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 03/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/13/2025
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 3
Control Number 56-AS-20250311092303
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: 03/13/2025
NARRATIVE
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During the facility visit today, 03/13/2025, LPA Brown together with ED Roper observed that there's one (1) busted bulb in R1's bathroom and LPA Brown noted the the center of R1's bathroom ceiling will not turn on as well. During the facility visit today, the facility's Maintenance Director replaced the busted bulb and repaired the light at the center of R1's bathroom ceiling.

Second allegation: Staff did not ensure the aluminum threshold ramp was fixed/replaced to meet a resident needs. The investigation was conducted by LPA Melody Brown which consisted of observation and interviews with relevant parties. During the investigation, LPA Brown was able to obtain sufficient evidence to support that staff did not ensure the aluminum threshold ramp was fixed/replaced to meet a resident needs. LPA Brown interviewed R1 and R1 indicated that it's difficult for R1 to go in and out of R1's room due to the aluminum threshold ramp on the entryway of R1's room. LPA Brown interviewed four (4) of four (4) residents on wheelchair and they revealed that it's hard for all of them as well to get in and out of their room due to the aluminum threshold ramp on their entryway. Interview with S3 indicated that S3 was aware and observed most of residents on wheelchair at the facility were having difficulty wheeling themselves in and out of their room due to the aluminum threshold ramp on their entryway.During the facility visit today, 03/13/2025, LPA Brown observed R1 having difficulty wheeling in and out of R1's room. LPA Brown noted that it is a safety hazard as well due to R1's failing eyesight.

Therefore, based on the evidence obtained during LPA Brown's investigation, there's sufficient evidence to prove that staff did not ensure light was fixed properly in resident bathroom (Allegation #1), staff did not ensure the aluminum threshold ramp was fixed/replaced to meet a resident needs (Allegation #2), are SUBSTANTIATED. A finding that the complaint is SUBSTANTIATED means that the allegation of staff did not ensure light was fixed properly in resident bathroom (Allegation #1), staff did not ensure the aluminum threshold ramp was fixed/replaced to meet a resident needs (Allegation #2) are valid because the preponderance of the evidence standard has been met.

An exit interview was conducted where this report (LIC9099), LIC9099D and Appeal Rights were discussed and provided to ED Karen Roper.

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

DATE: 03/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/13/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Citations on this Visit Report are Under Appeal!

Control Number 56-AS-20250311092303
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/13/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Under Appeal
Type B
03/21/2025
Section Cited
CCR
87303(a)
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87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety... This requirement is not met as evidenced by:
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Licensee replaced the one (1) busted bulb on top of the bathroom mirror and repaired the light at the center of R1's bathroom ceiling during the visit todaty, 03/13/2025. Plan of Correction (POC) cleared.
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Based on observation and interview, the Licensee did not comply with the section cited above by not ensuring that the light in R1's bathroom at the center of the ceiling and the one (1) bulb on top of bathroom mirror were working and not in disrepair which poses a potential safety and personal rights risk to resident in care.
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Under Appeal
Type B
03/21/2025
Section Cited
CCR
87307(d)(4)
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87307 Personal Accommodations and Services (d) The following space and safety provisions shall apply to all...(4) Stairways, inclines, ramps and open porches and areas of potential hazard to residents with poor balance or eyesight... This requirement is not met as evidenced by:
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License ordered a flat aluminum threshold during the visit today, 03/13/2025 for R1 and stated that they will install a sturdy hand railing for R1 on R1's entryway and submit proof to LPA Brown by the POC due date.
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Based on observation and interview, the Licensee did not comply with the section cited above by not ensuring that the aluminum threshold ramp on the entryway of R1's room with failing eyesight was not hard to wheel in or wheel out or has sturdy hand railings which poses a potential health, safety and personal rights risk to resident 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: Melody Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 03/13/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/13/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3