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

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 366410678
Report Date: 02/10/2025
Date Signed: 02/10/2025 12:01:52 PM

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
02/05/2025 and conducted by Evaluator Eldin Serrano
COMPLAINT CONTROL NUMBER: 56-AS-20250205094501
FACILITY NAME:CANYON HILLS CARE HOMEFACILITY NUMBER:
366410678
ADMINISTRATOR:MELJORIE CASTELOFACILITY TYPE:
740
ADDRESS:7791 STEWART ROADTELEPHONE:
(909) 433-0612
CITY:COLTONSTATE: CAZIP CODE:
92324
CAPACITY:6CENSUS: 5DATE:
02/10/2025
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Meljorie Castelo, Administrator/LicenseeTIME COMPLETED:
12:15 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not follow Emergency Disaster Plan
Staff do not have required medication training
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 2/10/2025 at 9:30 AM, Licensing Program Analyst (LPA) Eldin Serrano arrived at the facility to investigate a complaint and deliver the findings for the above complaint allegation. Upon arrival, LPA Serrano met with the caregiver Myrna Sapigao and immediately called the Administrator/Licensee Meljorie Castelo who arrived ten (10) minutes later. LPA Serrano informed administrator of the purpose of the visit.

The investigation consisted of file review, observation and interviews with relevant parties.The department received a complaint on 02/05/2025 regarding the following allegations:

#1 Staff did not follow Emergency Disaster Plan. During the interview with the licensee, the licensee stated that they had an emergency shutdown of electricity in the area in which the Southern California Edison (SCE) did not give prior notification for the ouatge on 1/9/2025 which SCE usually do for scheduled outages.

****continue on LIC9099C*****
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Eldin Serrano
LICENSING EVALUATOR SIGNATURE:

DATE: 02/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2025
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-20250205094501
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: CANYON HILLS CARE HOME
FACILITY NUMBER: 366410678
VISIT DATE: 02/10/2025
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
 Licensee stated that they purchased a portable stove the day after the outage and was not prepared for that emergency outage. Since their water supply is from their own private water well, it needs electricity for it to work. Based on observation, the facility has a 50 gallon water container reserve for washing and hygiene use. Licensee, provided warm food and sandwiches the day of the outage from outside source. They used the portable stove the next day to provide warm food for the residents and to warm the water for daily hygiene for the residents. No residents medication needs refrigeration. Licensee stated that their personal residence is three (3) miles away from the facility and can bring enough supply/items as needed. Upon review of the Emergency Disaster Plan, the allegation corroborates that the licensee did not follow the emergency disaster plan because they have a non-working generator which the licensee stated that they tried to turn on at the time of the power outage but no longer working. That made the facility unprepared for the emergency by not ensuring all the equipment is in working condition. LPA will issue a citation.

#2 Staff do not have required medication training. Based on file review of the staff, LPA observed that the medication training was dated on 01/17/2025 for two (2) direct support professional (DSP) Staff #1 (S1) and Staff #2 (S2). The certificates were not readily available upon the inspection of the reporting party (RP) 01/14/2025 in which the two DSP were already administering medication without the proper training and certification. LPA will issue a citation.

Based on LPA's observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6 Chapter 8), are being cited on the attached LIC 9099D.

An exit interview was conducted where this report LIC9099, LIC9099C, LIC9099D, and Appeal Rights were discussed and provided to Licensee Meljorie Castelo.


****This is an amendment to the original LIC9099C****
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Eldin Serrano
LICENSING EVALUATOR SIGNATURE:

DATE: 02/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 56-AS-20250205094501
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: CANYON HILLS CARE HOME
FACILITY NUMBER: 366410678
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/10/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/28/2025
Section Cited
CCR
87212(b)(2)(E)
1
2
3
4
5
6
7
87212 Emergency Disaster Plan
(b) The plan shall be subject to review...(2) Plan for evacuation including:(E) Relocation sites... to provide safe temporary accommodations for residents.
This is not met as evidence by:
1
2
3
4
5
6
7
Licensee will submit the statement of understanding to follow 87212(b)(2)(E) regulation regarding emergency disaster plan and the licensee will provide proof of purchase and installation of a new generator for the facility by the plan of correction (POC) due date
8
9
10
11
12
13
14
Based on observation, file review and interview the licensee did not comply with the section cited above by not ensuring that the facility followed the emergency disaster plan which poses a potential health, safety or personal rights risk to persons in care.
8
9
10
11
12
13
14
Type B
02/12/2025
Section Cited
CCR
87411(c)(3)(D)
1
2
3
4
5
6
7
87411 Personnel Requirements - General
(c) All RCFE staff who assist residents... shall receive initial and annual training...(3)The training shall include, but not be limited to, the following:(D)Policies and procedures regarding medications...This is not met as evidence by:
1
2
3
4
5
6
7
Licensee will submit a statement of understanding of 87411(c)(3)(D) by the POC due date.
8
9
10
11
12
13
14
Based on observation, the licensee did not comply with the section cited above by not ensuring that the staff has the required medication training prior to administreing medication to residents which poses a potential health, safety or personal rights risk to 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: Karen Clemons
LICENSING EVALUATOR NAME: Eldin Serrano
LICENSING EVALUATOR SIGNATURE:

DATE: 02/10/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3