366426335-2-23-2026-56-AS-NBRN-DRWUKR-20260306143932

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 366426335
Report Date: 02/23/2026
Date Signed: 02/23/2026 05:00:23 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
01/26/2024 and conducted by Evaluator Renese Howell-Small

COMPLAINT CONTROL NUMBER: 56-AS-20240126083631

FACILITY NAME:	KNOLLS WEST ASSISTED LIVING		FACILITY NUMBER:	366426335
ADMINISTRATOR:	TERRONSAY WHALEY		FACILITY TYPE:	740
ADDRESS:	16890 GREEN TREE BLVD.		TELEPHONE:	(760) 245-0107
CITY:	VICTORVILLE	STATE: CA	ZIP CODE:	92395
CAPACITY:	64	CENSUS: 52	DATE:	02/23/2026
		UNANNOUNCED	TIME BEGAN:	09:40 AM
MET WITH:	Assistant Administrator, Janeth Gonzalez		TIME COMPLETED:	05:10 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Residents sustained multiple bedsores due to staff neglect
Facility staff did not meet residents’ hygiene needs
Facility staff did not ensure residents had clean bed linens
Facility staff did not ensure residents had clean clothing
Facility staff did not meet residents’ grooming needs
Facility staff served residents food of poor quality
Facility staff withheld food from residents
Facility staff were not trained on procedures regarding medications before dispensing medications
Facility staff spoke inappropriately to residents

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

On 02/23/2026 at 9:40AM Licensing Program Analyst (LPA) Renese Howell-Small conducted an unannounced visit to the facility to deliver findings for the above allegations. LPA met with Assistant Admnistrator, Janeth Gonzalez, introduced self and stated the purpose of the visit.

It is alleged that residents sustained multiple bedsores due to staff neglect. LPA conducted interviews with residents and staff. Resident 1 (R1) no longer resides at the facility and was unable to be interviewed. Record review confirmed R1 left the facility on 01.23/2024. LPA interviewed a relative of R1 who stated that they did not have any concerns with the care that was provided to R1 and denied the allegation. Interviews with staff revealed they currently have no residents with bedsores. Based on interviews conducted with the relative of R1 and staff, and a review of records, the allegation is UNSUBSTANTIATED.

It is alleged that facility staff did not meet residents' hygiene needs. LPA conducted interviews with residents and staff. Residents stated that staff assist them with their hygiene needs when needed and denied that staff
do not meet their hygiene needs. LPA interviewed staff and staff denied the allegation. Based on interviews

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Renese Howell-Small
LICENSING EVALUATOR SIGNATURE:	DATE: 02/23/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2026

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-20240126083631

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: KNOLLS WEST ASSISTED LIVING	FACILITY NUMBER: 366426335
	VISIT DATE: 02/23/2026

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

conducted with residents and staff, this allegation is UNSUBSTANTIATED.

It is alleged that facility staff did not ensure residents had clean bed linens. LPA observed a sufficient amount of clean bed linens in the storage room. LPA conducted a tour of resident bedrooms and observed clean linen on each of their beds. LPA interviewed staff and staff denied the allegation. LPA interviewed residents and residents denied the allegation.

It is alleged that facility staff did not ensure residents had clean clothing. LPA observed residents clothing to be clean and in good condition. LPA interviewed staff and staff denied the allegation, stating that residents' clothes are changed when appropriate. LPA interviewed residents and residents denied the allegation. Based on observation and interview, the allegation is UNSUBSTANTIATED.

It is alleged that facility staff did not meet residents' grooming needs. LPA interviewed residents and residents stated that staff assist with their grooming needs. Residents denied the allegation. LPA interviewed staff and staff stated that residents are assisted with their needs by staff or a professional. Staff denied the allegation. Based on interview and observation, the allegation is UNSUBSTANTIATED.

It is alleged that facility staff served residents food of poor quality. LPA conducted a tour of the facility's kitchen and pantry. LPA observed the food to be varied and of good quality. LPA interviewed staff and residents. Both staff and residents denied the allegation. Based on interview and observation, the allegation is UNSUBSTANTIATED.

It is alleged that facility staff withheld food from residents. LPA interviewed residents and residents denied the allegation. LPA interviewed staff and staff stated that food is always available to residents. Staff denied the allegation. Based on interview, the allegation is UNSUBSTANTIATED.

It is alleged that facility staff were not trained on procedures regarding medications before dispensing medications. LPA interviewed staff. Staff stated that only staff that are trained in medication procedures can administer medications. Staff denied the allegation. Based on interviews, the allegation is UNSUBSTANTIATED.

It is alleged that staff spoke inappropriately to residents. LPA interviewed residents and stated that have not

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Renese Howell-Small
LICENSING EVALUATOR SIGNATURE:	DATE: 02/23/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2026

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 56-AS-20240126083631

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: KNOLLS WEST ASSISTED LIVING	FACILITY NUMBER: 366426335
	VISIT DATE: 02/23/2026

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

witnessed staff speaking inappropriately to residents. Residents denied the allegation. LPA interviewed staff and staff denied witnessing the allegation. Based on interviews, the allegation is UNSUBSTANTIATED.

An UNSUBSTANTIATED complaint 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 occurred.

An exit interview was conducted where this report LIC9099 and LIC9099C were discussed and copies were provided to Assistant Administrator, Janeth Gonzalez.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Renese Howell-Small
LICENSING EVALUATOR SIGNATURE:	DATE: 02/23/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2026

LIC9099 (FAS) - (06/04)

Page: 3 of 3