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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 335530171
Report Date: 04/29/2025
Date Signed: 04/29/2025 03:48:10 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
01/10/2025 and conducted by Evaluator Raquel Hernandez
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20250110161617
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:
04/29/2025
UNANNOUNCEDTIME BEGAN:
11:40 AM
MET WITH:Administrator Karen Roper TIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Staff do not keep the facility clean & sanitary
Facility dining room has been closed for an extended period of time
Staff prohibit resident from making phone calls
Staff isolate residents in their rooms
Staff do not assist resident with medical appointments
Staff did not obtain medical assistance for resident in a timely manner
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Raquel Hernandez conducted an unannounced visit for the delievering findings of allegations listed above. LPA met with Administrator Karen Roper and explained today's visit. Investigation consisted of staff and resident interviews along with request of documentation.

For the allegation, Staff do not keep the facility clean & sanitary

LPA Hernandez conducted (8) resident interviews. 8 out of the 8 stated the facility is kept clean and sanitary everyday. Addtionally, LPA Hernandez observed Housekeeping schedule. LPA Hernandez conducted (8) staff interviews. 8 out of the 8 staff stated the facility is kept clean and sanitized everyday.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Raquel Hernandez
LICENSING EVALUATOR SIGNATURE:

DATE: 04/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2025
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-20250110161617
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: WILDOMAR SENIOR ASSISTED LIVING
FACILITY NUMBER: 335530171
VISIT DATE: 04/29/2025
NARRATIVE
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For the allegation, Facility dining room has been closed for an extended period of time

Administrator Karen Roper stated the facility dining room was closed between a three week time period due to a stomach flu outbreak. Administrator stated food trays were taken up to residents rooms and residents were asked to stay in their bedrooms to avoid getting sick.

For the allegation, Staff prohibit resident from making phone calls

LPA Hernandez conducted (8) resident interviews. 8 out of the 8 stated they are not prohibited from making phone calls. Additionally, Resident #6 (R6) stated phone call services are offered at the facility if resident doesn't have a personal cell phone.

For the allegation, Staff isolate residents in their rooms

LPA Hernandez conducted (8) resident interviews. 8 out of the 8 stated they are not isolated in their bedrooms. Resident #4 (R4) stated activities are offered and depends on the resident if they would like to attend activity. LPA Hernandez conducted (8) staff interviews. 8 out of the 8 stated residents are not isolated in their bedrooms. 8 out of the 8 stated residents are encouraged to come out of their rooms and participate in the various amount of activities that the facility offers.

For the allegation, Staff do not assist resident with medical appointments

LPA Hernandez conducted (8) resident interviews. 8 out of the 8 stated the facility does offer assistance with medical appointments. However, 6 out of the 8 residents are able to make their own appointments or a family member makes them and provides transportation to medical appointments

For the allegation, Staff did not obtain medical assistance for resident in a timely manner.

LPA Hernandez conducted (8) resident interviews. 4 out of the 8 stated facility staff assist with medical assistance when needed. The additional 4 residents stated they have not needed medical assistance but facility staff do assist others with such. Administrator Karen Roper stated all residents are helped in a timely manner with medical assistance.

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

DATE: 04/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 56-AS-20250110161617
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: WILDOMAR SENIOR ASSISTED LIVING
FACILITY NUMBER: 335530171
VISIT DATE: 04/29/2025
NARRATIVE
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Based on the evidence gathered during today’s investigation, the allegations listed above are deemed UNSUBSTANTIATED. A finding that the complaints are UNSUBSTANTIATED means although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

During today’s visit pertaining to the allegation listed, no deficiency was 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: Raquel Hernandez
LICENSING EVALUATOR SIGNATURE:

DATE: 04/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3