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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 361880786
Report Date: 10/29/2025
Date Signed: 10/29/2025 02:35:51 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,
, CA
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/13/2021 and conducted by Evaluator Yolanda Delgado
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20210713153425
FACILITY NAME:SOMERFORD PLACE-REDLANDSFACILITY NUMBER:
361880786
ADMINISTRATOR:TURNER, DANICA JFACILITY TYPE:
740
ADDRESS:1319 BROOKSIDE AVENUETELEPHONE:
(909) 793-9500
CITY:REDLANDSSTATE: CAZIP CODE:
92373
CAPACITY:75CENSUS: 47DATE:
10/29/2025
UNANNOUNCEDTIME BEGAN:
01:20 PM
MET WITH:Rachelle Wheaton, Administrator & Jonathan Guzman, Business Office ManagerTIME COMPLETED:
02:45 PM
ALLEGATION(S):
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Staff neglect resulted in resident death
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Yolanda Delgado, arrived unannounced to conclude a complaint investigation into the allegation of staff neglect resulted in resident death. LPA met with Administrator, Rachelle Wheaton and discussed the purpose of the visit. Rachelle had to excuse herself due to a prior engagment, Business Office Manager, Jonathan Guzman met with LPA. Rachelle returned during the discussion of the report. During the investigation, interviews were conducted with facility staff and residents and records were obtained and reviewed.

On July 10, 2021, Community Care Licensing received a complaint alleging staff’s neglect resulted in resident’s death. It was reported R1 was at the facility having lunch in the dining room when R1 started choking. Based on the review of the Ambulance Billing Report (ABR) dated July 10, 2021, facility staff called emergency services at 12:08 pm and emergency services personnel arrived at 12:12 pm. The ABR report indicates under Dispatch Information, the “Complaint at Disp:” is listed as choking. Emergency Services Personnel was at patient’s side at 12:14 pm and “immediately began HQ CPR”. (Continued on Page 2)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Yolanda Delgado
LICENSING EVALUATOR SIGNATURE:

DATE: 10/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2025
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 4
Control Number 18-AS-20210713153425
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
FACILITY NAME: SOMERFORD PLACE-REDLANDS
FACILITY NUMBER: 361880786
VISIT DATE: 10/29/2025
NARRATIVE
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(Continued from Page 1)

HQ CPR is abbreviated for high-quality cardiopulmonary resuscitation. Fire medical services observed that R1’s passageway was obstructed with food and removed the food with forceps. R1 began to have a pulse. R1 was transported to the hospital for further evaluation and care. Based on hospital records dated July 10, 2021, medical personnel advised R1’s responsible party that R1 was “developing post hypoxic myoclonic epilepsy activity in the setting of approximately 15 minutes downtime without adequate brain oxygenation leading to likely permanent anoxic brain injury”. Hospital records dated July 12, 2021, reveal at 1740 hours, medical personnel were called to R1’s room due to R1 was “without heart rate or breathing. Pupils fixed no spontaneous heart rate no spontaneous breathing time of death 1740 hours cause of death anoxic brain injury from cardiac arrest from choking.”

Information obtained from interviews revealed the following: a staff witness revealed they heard R1 coughing and gave R1 a cup of water. R1 continued to cough. The staff indicated R1 was asked if they were okay and R1 responded with their hands in a motion perceived by the staff to indicate that R1 was okay. Due to R1’s continued coughing, the staff called for Med Tech Rita Ortiz. Ortiz responded within 5 minutes, asking R1 if they were okay, to which R1 responded using the same hand motions. Ortiz then instructed the staff to stay with R1 while Ortiz left the area to call 911. It was reported Ortiz did not return to the common lunchroom until emergency services personnel arrived at the facility. Ortiz was interviewed and reported she received a call from another staff. Ortiz responded to the common lunchroom in less than one minute to assess R1. Ortiz reports R1 took a sip of water and motioned with their hands that they were okay. The staff pointed out R1 was gurgling. Ortiz instructed this staff to stay with R1 while she called 911. Ortiz contacted 911 and then started paperwork in preparation for emergency services personnel to arrive. Ortiz reports she did not think R1 was choking because R1 took a sip of water. Ortiz reports she observed R1’s face to change color but R1 was still breathing. Ortiz further reports she did not think R1 required cardiopulmonary resuscitation (CPR) because R1 was breathing and conscious. Ortiz reports that when she called 911, she reported R1 was conscious but was not feeling well. This contradicts the ABR which indicates the call came in as choking. Ortiz reports the 911 operator instructed her to call back if anything changed and to have someone watch R1. Ortiz explained the other staff was already with R1 at the time. The staff who was left to watch R1 was hired on May 20, 2021. The staff reported they had not yet had CPR or first aid training at the time of the incident.
(Continued on Page 3)
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Yolanda Delgado
LICENSING EVALUATOR SIGNATURE:

DATE: 10/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 18-AS-20210713153425
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
FACILITY NAME: SOMERFORD PLACE-REDLANDS
FACILITY NUMBER: 361880786
VISIT DATE: 10/29/2025
NARRATIVE
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(Continued from Page 2)

Death certificate dated September 3, 2021, revealed immediate cause of death is anoxic encephalopathy and obstruction of the airway by food. Interviews confirmed staff did not perform first aid to R1 during the choking incident. R1 exhibited signs such as coughing, turning color and gurgling. R1’s presence in the lunchroom along with the fact they were eating at the time of the incident further indicates first aid was needed. According to mayoclinic.org, choking is a life-threatening emergency because it cuts off oxygen to the brain, and therefore, first aid (abdominal thrust) should be performed immediately.

The allegation that staff neglect resulted in R1’s death is substantiated. The preponderance of evidence standard has been met. The facility will be cited for violation of California Code of Regulations, Title 22, Division 6, Chapter 8, Sections 87468.2(a)(8) and 87411(a). This poses a health and safety risk to clients in care.

A substantiated finding means that the allegation is valid because the preponderance of evidence standard has been met. In addition, this violation posed an immediate Health and Safety risk to resident(s) in care. An Immediate Civil Penalty of $500 is being assessed. The licensee was also informed that a civil penalty may be assessed based on Health and Safety Code § 1569.49.

An exit interview was conducted, a copy of this report, along with the 9099-D, Civil Penalties and appeal rights were provided to Administrator Rachelle Wheaton and Business Office Manager Jonathan Guzman.
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Yolanda Delgado
LICENSING EVALUATOR SIGNATURE:

DATE: 10/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 18-AS-20210713153425
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

FACILITY NAME: SOMERFORD PLACE-REDLANDS
FACILITY NUMBER: 361880786
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/29/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/30/2025
Section Cited
HSC
87468.2(a)(8)
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87468.2(a)(8) Additional Personal Rights of Residents in Privately Operated Facilities
(a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of
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Licensee will ensure that all care staff/med tech in the care department will be CPR/First Aid training as well as in-services training with all staff. Licensee will email copies of the current care staff CPR/First Aid training with in-service training to LPA by POC due date.
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the following personal rights:
(8) To be free from neglect, financial exploitation, involuntary seclusion, punishment, humiliation, intimidation, and verbal, mental, physical, or sexual abuse. This requirement was not met as evidenced by: Based on interviews and records reviewed staff neglect resulted in R1's death. This poses a potential health, safety, or personal rights risk to residents in care.
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Type B
11/05/2025
Section Cited
CCR
87411(a)
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Personnel Requirements: General
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:
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Licensee confirmed S1 is no longer an employee. Licensee will ensure in-service on the requirements and expectation of their duties while on duty, will email copies to LPA by POC due date.
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based on interviews and records reviewed S1 failed to demonstrate competency when she did not perform first aid. This poses a potential health, safety, or personal rights risk to residents 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: Jazmond D Harris
LICENSING EVALUATOR NAME: Yolanda Delgado
LICENSING EVALUATOR SIGNATURE:

DATE: 10/29/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 4