<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 335530186
Report Date: 10/24/2025
Date Signed: 10/24/2025 09:38:18 AM

Substantiated


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
10/06/2025 and conducted by Evaluator Hannah Rodgers
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20251006094602
FACILITY NAME:PEPPERMINT RIDGEFACILITY NUMBER:
335530186
ADMINISTRATOR:BARRON, STEPHANIEFACILITY TYPE:
740
ADDRESS:648 LOCUST STTELEPHONE:
(951) 273-7320
CITY:CORONASTATE: CAZIP CODE:
92879
CAPACITY:4CENSUS: 4DATE:
10/24/2025
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Operations Manager Jessica PazTIME COMPLETED:
09:45 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Licensee did not ensure the facility had sufficient staffing.
Licensee falsified records.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Hannah Rodgers conducted an unannounced visit to deliver findings regarding the above complaint allegations. LPA introduced herself and disclosed the purpose of the visit to Operations Manager Jessica Paz.

On October 6, 2025, it was alleged that licensee did not ensure the facility had sufficient staffing and licensee falsified records. The Department’s investigation consisted of an unannounced facility visit, records review, and staff and resident interviews.

According to the allegations received, Resident #1 (R1) requires a Hoyer lift and two staff members to transfer them. However, the facility was understaffed and there have been incidents where there is only one staff member at the facility. Also, the staff were incorrectly filling out Medication Administration Records (MARs) and other pertinent documents at the facility.
[Continued on LIC9099-C]
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Hannah Rodgers
LICENSING EVALUATOR SIGNATURE:

DATE: 10/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2025
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 5
Control Number 56-AS-20251006094602
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: PEPPERMINT RIDGE
FACILITY NUMBER: 335530186
VISIT DATE: 10/24/2025
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Review of R1’s medical assessment date May 22, 2025, revealed that R1 is non-ambulatory and can feed themself but required assistance with all other Activities of Daily Living (ADLs). Interviews revealed that R1 requires a Hoyer lift to be transferred to their wheelchair from their bed. Interviews also revealed that the Hoyer lift requires two (2) staff members, and there have been instances where there is only one (1) staff member on-site at the facility. Due to only one (1) staff member being present at the facility, R1 could not be transferred until another staff member had to be called to come to the facility and assist with the transfer.

During LPA’s initial visit on October 14, 2025, from 9:20AM-11:15AM, LPA reviewed facility records. Review of the residents’ MARs revealed that a staff member had initiated an administration at 12:00PM prior to it being 12:00PM. Review of R1’s repositioning checklist also revealed that a staff member had initialed the repositioning of R1 at 12:00PM and at 2:00PM prior to those times.

The Department has investigated the above-mentioned allegations and based on interviews and records review, the preponderance of evidence exists to support the allegations. Two deficiencies are being cited per California Code of Regulations, Title 22 (refer to the attached LIC 9099-D). An exit interview was conducted with Operations Manager Jessica Paz, to whom a copy of this report, LIC 9099-C, LIC 9099-D, and the Licensee/Appeal Rights (LIC 9058 03/22) were provided to.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Hannah Rodgers
LICENSING EVALUATOR SIGNATURE:

DATE: 10/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 56-AS-20251006094602
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: PEPPERMINT RIDGE
FACILITY NUMBER: 335530186
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/24/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/21/2025
Section Cited
CCR
87411(a)
1
2
3
4
5
6
7
87411 Personnel Requirements - General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs...
This requirement was not met as evidenced by:
1
2
3
4
5
6
7
Licensee agrees to conduct an in-house training on staffing requirements and submit training agenda and sign-in sheet to the Department by POC date of 11/21/2025.
8
9
10
11
12
13
14
Based on interviews and records review, the licensee did not comply with the section cited above in that there was not sufficient number of staff to transfer Resident #1 (R1) which posed a potentional health, safety, or personal rights risk to one (1) out of four (4) persons in care.
8
9
10
11
12
13
14
Type B
11/21/2025
Section Cited
CCR
87207
1
2
3
4
5
6
7
87207 False Claims
No licensee... or employee of a licensee shall make or disseminate any false or misleading statement regarding ... any of the services provided by the facility.
This requirement was not met as evidenced by:
1
2
3
4
5
6
7
Licensee agrees to conduct an in-house training on medication administration and submit training agenda and sign-in sheet to the Department by POC date of 11/21/2025.
8
9
10
11
12
13
14
Based on records review, the licensee did not comply with the section cited above in that resident records were falsely filled out in advance for Resident #1 (R1) which posed a potential health and safety risk to one (1) out of four (4) persons in care
8
9
10
11
12
13
14
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: Hannah Rodgers
LICENSING EVALUATOR SIGNATURE:

DATE: 10/24/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 5
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
10/06/2025 and conducted by Evaluator Hannah Rodgers
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20251006094602

FACILITY NAME:PEPPERMINT RIDGEFACILITY NUMBER:
335530186
ADMINISTRATOR:BARRON, STEPHANIEFACILITY TYPE:
740
ADDRESS:648 LOCUST STTELEPHONE:
(951) 273-7320
CITY:CORONASTATE: CAZIP CODE:
92879
CAPACITY:4CENSUS: 4DATE:
10/24/2025
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Operations Manager Jessica Paz TIME COMPLETED:
09:45 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not meet resident’s transfer needs.
Staff did not have medication training.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Hannah Rodgers conducted an unannounced visit to deliver findings regarding the above complaint allegations. LPA introduced herself and disclosed the purpose of the visit to Operations Manager Jessica Paz.

On October 6, 2025, it was alleged that staff did not meet resident’s transfer needs and staff did not have medication training. The Department’s investigation consisted of an unannounced facility visit, records review, and staff and resident interviews.

According to the allegations received, Resident #1 (R1) requires a Hoyer lift and two staff members to transfer them. However, the licensee was making one staff member transfer R1. Also, it was alleged that the staff members at the facility are untrained in medication administration.

[CONTINUED ON LIC9099-C]
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Hannah Rodgers
LICENSING EVALUATOR SIGNATURE:

DATE: 10/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 56-AS-20251006094602
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: PEPPERMINT RIDGE
FACILITY NUMBER: 335530186
VISIT DATE: 10/24/2025
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Review of R1’s medical assessment date May 22, 2025, revealed that R1 is non-ambulatory and can feed themself but required assistance with all other Activities of Daily Living (ADLs). Interviews revealed that R1 requires a Hoyer lift to be transferred to their wheelchair from their bed and the Hoyer lift requires two (2) staff members to operate it. Interviews did not reveal that staff have transferred R1 with only one (1) staff member nor have staff operated the Hoyer lift if they are the only staff on site at the facility. Review of staff training records did not reveal that staff are untrained in medications. Records reviewed revealed that current medication trainings were maintained on file for staff members.

Based on interviews and records review, the investigation did not yield a preponderance of evidence to conclude that staff did not meet resident’s transfer needs and staff did not have medication training. Based on the foregoing, the allegations are unsubstantiated. This finding means that although the allegation may have happened or may be valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. An exit interview was conducted with Operations Manager Jessica Paz, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Hannah Rodgers
LICENSING EVALUATOR SIGNATURE:

DATE: 10/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5