335530171-5-28-2025-56-AS-KCLS-DH5UTG-20250529155156

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 335530171
Report Date: 05/28/2025
Date Signed: 05/28/2025 10:22:48 AM

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
05/19/2025 and conducted by Evaluator Melody Brown

PUBLIC

COMPLAINT CONTROL NUMBER: 56-AS-20250519145753

FACILITY NAME:	WILDOMAR SENIOR ASSISTED LIVING		FACILITY NUMBER:	335530171
ADMINISTRATOR:	YOUSEFIAN, ROSE		FACILITY TYPE:	740
ADDRESS:	32365 SOUTH PASADENA ST		TELEPHONE:	(323) 902-6000
CITY:	WILDOMAR	STATE: CA	ZIP CODE:	92595
CAPACITY:	200	CENSUS: 121	DATE:	05/28/2025
		ANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Executive Director Karen Roper		TIME COMPLETED:	10:30 AM

ALLEGATION(S):

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Staff did not prevent resident from developing a pressure injury.
Staff did not ensure resident’s room was free from odors.
Staff did not ensure that a resident is using clean linen at all times.
Staff did not adequately assist resident with care needs.

INVESTIGATION FINDINGS:

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On 05/28/2025 at 09:00 AM, Licensing Program Analyst (LPA), Melody Brown, met with Executive Director (ED) Karen Roper at Community Care Licensing Division (CCLD) Adult and Senior Care (ASC) San Bernardino (SB) Regional Office to deliver complaint investigation findings for the above allegations. LPA Brown explained the purpose of the requested Office Visit to ED Roper. After introducing and identifying self, LPA Brown discussed the findings to ED Roper.

The investigation was conducted by LPA Melody Brown. The investigation consisted of file review, observation and interviews with relevant parties. The first allegation indicates that staff did not prevent residents from developing a pressure injury. During the investigation, LPA Brown did not find evidence to corroborate the allegation. Interviews with four (4) of four (4) residents indicated that staff at the facility are checking on them five (5) times a day to determine if they needed a change, they needed assistance or to rotate them. LPA Brown unable to interview Resident #1 (R1) as R1 unable to answer LPA Brown's questions. Four (4) of four (4) residents interviewed denied developing or having a pressure injury. Eight (8) of eight (8) staff interviewed reported that **Cont.in LIC9099C***

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE:	DATE: 05/28/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2025

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-20250519145753

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: 05/28/2025

NARRATIVE

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they are checking on their residents every two (2) hours to change a resident if needed, to rotate a resident or if resident need assistance. Interviews with eight (8) of eight (8) staff indicated that there's no incident at the facility that they neglected R1, and they did not prevent R1 from developing pressure injury. Records review revealed that R1's on hospice care and receiving wound care. Interview with R1 hospice nurse on 05/22/2025 revealed that it was not due to staff neglect because R1 developed pressure injury but due to R1's change of condition and gradually decline in addition to R1 refusing care and severe agitation. Moreover, R1 hospice nurse stated that due to R1 declining health condition that started few weeks ago, they put R1 on comfort care medications.

The second allegation indicates that staff did not ensure resident’s room was free from odors. During the investigation, LPA Brown was not able to obtain sufficient evidence to corroborate the allegation. Four (4) of four (4) residents interviewed reported that staff at the facility clean their room every week and they stated that all staff at the facility ensure that their room was free from odors. LPA Brown unable to interview R1 as R1 unable to answer LPA Brown's questions. Interviews with nine (9) of nine (9) staff indicated that housekeeping staff are cleaning residents’ rooms once a week and care staff make sure that trash, food trays, leftover food are picked up daily to ensure that residents’ rooms are free from odors. Nine (9) of nine (9) staff interviewed said that there's no incident at the facility that they did not ensure that R1's room was free from odors. Records review showed that all housekeeping staff have a schedule to clean all residents’ rooms weekly. During the facility visit on 05/22/2025, LPA Brown observed that R1's room was clean and free from odors.

The third allegation indicates that staff did not ensure that a resident is using clean linen at all times. During the investigation, LPA Brown did not find evidence to corroborate the allegation. Interviews with four (4) of four (4) residents indicated that all staff at the facility make sure that they always have clean linens. LPA Brown unable to interview R1 as R1 unable to answer LPA Brown's questions. Nine (9) of nine (9) staff reported that there's no incident at the facility that they did not ensure that their residents are using clean linens. Interviews with nine (9) of nine (9) staff revealed that they are changing their residents’ linens weekly and if they observed that a resident linen is dirty, they immediately change it. Nine (9) of nine (9) staff denied not ensuring that R1 always has clean linen. During the facility visit on 05/22/2025, LPA Brown observed R1 linens clean.

The fourth allegation indicates staff did not adequately assist resident with care needs. During the investigation, LPA Brown was not able to obtain sufficient evidence **Continuation in LIC9099C**

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE:	DATE: 05/28/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2025

LIC9099 (FAS) - (06/04)

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Control Number 56-AS-20250519145753

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: 05/28/2025

NARRATIVE

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to corroborate the allegation. Four (4) of four (4) residents interviewed reported that all staff at the facility are adequately assisting them with their care needs as all staff are regularly checking on them if they need assistance and assisting them with their activities of daily living (ADLs). Interviews with four (4) of four (4) residents revealed that staff at the facility are meeting their care needs. LPA Brown unable to interview R1 as R1 unable to answer LPA Brown's questions. Interviews with eight (8) of eight (8) staff indicated that they all make sure that they are adequately assisting all their residents to meet their care needs. Eight (8) of eight (8) staff interviewed reported that there's no incident at the facility that staff did not adequately assist R1 with R1's care needs. An interview with R1 hospice nurse on 05/22/2025 indicated that all staff at the facility are providing the appropriate care for R1 to meet R1's needs. During the facility visit on 05/22/2025, LPA Brown observed staff at the facility working with R1 hospice nurse to ensure that they are adequately assisting R1 to meet R1's needs.

Therefore, based on the evidence obtained during tLPA Brown's investigation, there is insufficient evidence to prove that staff did not prevent resident from developing a pressure injury (Allegation #1), staff did not ensure resident’s room was free from odors (Allegation #2), staff did not ensure that a resident is using clean linen at all times (Allegation #3), staff did not adequately assist resident with care needs (Allegation #4) are UNSUBSTANTIATED at this time. Although the allegation of staff did not prevent resident from developing a pressure injury (Allegation #1), staff did not ensure resident’s room was free from odors (Allegation #2), staff did not ensure that a resident is using clean linen at all times (Allegation #3), staff did not adequately assist resident with care needs (Allegation #4) may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED at this time.

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

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE:	DATE: 05/28/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2025

LIC9099 (FAS) - (06/04)

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