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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 335530171
Report Date: 10/03/2025
Date Signed: 10/03/2025 03:49:04 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
06/17/2025 and conducted by Evaluator Renese Howell-Small
COMPLAINT CONTROL NUMBER: 56-AS-20250617192330
FACILITY NAME:WILDOMAR SENIOR ASSISTED LIVINGFACILITY NUMBER:
335530171
ADMINISTRATOR:KAREN ROPERFACILITY TYPE:
740
ADDRESS:32365 SOUTH PASADENA STTELEPHONE:
(323) 902-6000
CITY:WILDOMARSTATE: CAZIP CODE:
92595
CAPACITY:200CENSUS: 115DATE:
10/03/2025
UNANNOUNCEDTIME BEGAN:
01:20 PM
MET WITH:Executive Director, Karen RoperTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Staff do not give resident medication as prescribed
Staff do not ensure that resident's needs are met
Staff did not have resident's medication records available for emergency medical care
Staff illegally evicted resident
INVESTIGATION FINDINGS:
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On 10/03/2025 at 1:30PM Licensing Program Analyst (LPA) Renese Howell-Small conducted an unannounced visit to the facility in order to deliver findings for the above allegations. LPA discussed the purpose of the visit with Executive Director, Karen Roper. The investigation consisted of interviews and record review.

In regards to the allegation of staff do not give resident medication as prescribed :
LPA interviewed seven (7) staff and (10) residents. Staff stated that they have sufficient training in medication and denied the allegation. Residents stated that they receive their medication(s). LPA reviewed the Medication Administration Record (MAR) for R1 and did not observe any discrepancies. Based upon interviews and record review, this allegation is UNSUBSTANTIATED.

In regards to the allegation of staff do not ensure that resident's needs are met:
LPA reviewed Resident 1 (R1) Service Plan which confirmed that R1 mainly needed assistance with
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Renese Howell-Small
LICENSING EVALUATOR SIGNATURE:

DATE: 10/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
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Control Number 56-AS-20250617192330
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: 10/03/2025
NARRATIVE
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 medication administration. Staff stated that R1 was independent and did not require assistance with their Activities of Daily Living (ADL). Based upon interviews and record review, this allegation is UNSUBSTANTIATED.

In regards to the allegation of staff did not have resident's medication records available for emergency medical care :
Staff stated that the facility's policy is to provide residents' Face Sheet and Medication list when residents are sent out of the facility. The facility has a folder readily available with this information. Staff denied the allegation. The Reporting Party (RP) did not recall the details of this allegation. Based upon interviews, this allegation is UNSUBSTANTIATED.

In regards to the allegation of staff illegally evicted resident:
Staff stated that R1 voluntarily left the facility on 06/16/2025 because R1 would be moved to a Skilled Nursing facility. Staff denied the allegation. LPA did not observe any documentation regarding eviction in R1's file. Based upon interviews and record review, this allegation is UNSUBSTANTIATED.

LPA made several attempts to reach R1 but their contact numbers were disconnected. R1 was self-responsible. The RP stated that they did not observe or witness any of the above allegations but the family of R1 shared these concerns.

UNSUBSTANTIATED is defined as the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation(s) occurred.

An exit interview was conducted where this report LIC9099 and LIC9099C was discussed and a copy was provided to Executive Director, Karen Roper.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Renese Howell-Small
LICENSING EVALUATOR SIGNATURE:

DATE: 10/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2025
LIC9099 (FAS) - (06/04)
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