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

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 371881418
Report Date: 09/25/2025
Date Signed: 09/25/2025 11:27:28 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE 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
07/17/2024 and conducted by Evaluator Janira Arreola
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20240717163615
FACILITY NAME:VILLA BERNARDOFACILITY NUMBER:
371881418
ADMINISTRATOR:DERAFERA, TESSFACILITY TYPE:
740
ADDRESS:2960 BERNARDO AVETELEPHONE:
(858) 925-8858
CITY:ESCONDIDOSTATE: CAZIP CODE:
92029
CAPACITY:10CENSUS: 10DATE:
09/25/2025
UNANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:Staff, Rommel AbedozaTIME COMPLETED:
11:30 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Neglect/Lack of Care and Supervision resulted in hospitalization
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Janira Arreola conducted an unannounced visit in order to deliver findings for the above allegation. LPA met with Staff, Rommel Abedoza who was informed of the purpose of the visit. LPA spoke with the current administrator, Lynn Drummond and Licensee Zayden chen over the phone who were informed of the purpose of the visit. The investigation consisted of interviews and records review.

It was alleged “Neglect/Lack of Care and Supervision resulted in hospitalization” of Resident #1 (R1). It was alleged R1 developed an open wound with maggots due to neglect by facility staff.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Carolyn Tuba
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE:

DATE: 09/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2025
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-20240717163615
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: VILLA BERNARDO
FACILITY NUMBER: 371881418
VISIT DATE: 09/25/2025
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
Medical records for R1 dated 07/16/2024 revealed diagnosis of “pink skin with crawling maggots” between the toes, MRSA, Cellulitis, and non-pressure arterial ulcers on the toes of both feet. The medical records revealed R1 was admitted to the hospital on 07/16/2024.

Pre-placement appraisal for R1 dated 02/19/2024 documented a history of MRSA, Cellulitis, and a Stage 2 ulcer on R1’s right foot. A review of R1’s Home Health Care Plan dated 06/06/2024 revealed, R1 was admitted to home health services for treatment of Cellulitis to the lower extremities on 06/07/2024. Home Health services were discontinued on 06/28/2024 and home health notes read, “Bilateral wounds and weeping resolved without complications.”

A review of R1’s resident file revealed there was no documented care plan created or maintained by the facility for R1’s care. Interviews with three (3) facility staff revealed they were instructed by home health to continue wrapping R1’s legs with gauze following R1’s discharge from home health services. Staff interviews revealed the gauze was changed every two to three days. R1’s physician was interviewed and reported facility staff were instructed to change R1’s gauze daily and to monitor R1’s lower extremities closely.

R1’s Physician’s Report dated 02/16/2024 was reviewed. It revealed R1 was unable to bathe themselves and R1 required assistance with grooming of their lower body by a caregiver. Interviews with six (6) facility staff revealed R1 did not take showers and instead used washcloths for personal hygiene. Staff indicated they would hand the washcloth to R1 who then used the washcloth independently. Of the staff interviews, (3) of (6) staff reported R1 washed their own feet. When staff were asked about assisting R1 with putting on socks and shoes, staff reported they assisted R1 with this task because R1 was not able to bend down far enough to put on their own socks and shoes.

SUPERVISORS NAME: Carolyn Tuba
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE:

DATE: 09/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 18-AS-20240717163615
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: VILLA BERNARDO
FACILITY NUMBER: 371881418
VISIT DATE: 09/25/2025
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
On 07/11/2024, Staff #1 (S1) reported assisting R1 with bathing and stated they did not observe any sores on R1’s feet. On 07/12/2024 Staff #2 (S2) reported they washed R1’s feet and observed an open sore on the second toe of R1’s left foot. S2 stated they reported this sore to the administrator, however an interview with the administrator revealed they did not recall being notified of any sores. No documentation or evidence of follow-up or medical intervention for the sore was provided by the facility. On 07/16/2024, S1 reported seeing flies around R1’s feet, and upon removing the gauze, S1 observed maggots on R1’s feet. Emergency services were contacted, and R1 was transported to the hospital. Hospital photographs taken on 07/16/2024 revealed both of R1’s feet were red, swollen, with yellow and black buildup between and under the toes, flaking skin, and discoloration of the toenails.

Based on interviews and review of records and documentation, the preponderance of evidence standard has been met. Therefore, the allegation is substantiated. A violation of California Code of Regulations (Title 22, Division 6, Chapter 8) is cited on the attached LIC 9099-D. An immediate civil penalty in the amount of $500 is being assessed. In accordance with Health and Safety (H&S) Code Section 1569.49(e), the determination of additional civil penalties for a violation that resulted in a serious injury to the resident is pending and under review by the Department.

An exit interview was conducted, and this report, along with LIC 9099-D, LIC 421IM (civil penalty), and appeal rights were provided to the facility representative. A plan of correction was discussed and documented with licensee Zayden Chen and Lynn Drummond

SUPERVISORS NAME: Carolyn Tuba
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE:

DATE: 09/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 18-AS-20240717163615
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: VILLA BERNARDO
FACILITY NUMBER: 371881418
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/25/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied: Appeal Not Submitted Timely
Type A
09/26/2025
Section Cited
CCR
87465(a)(1)
1
2
3
4
5
6
7
87465 Incidental Medical and Dental Care(a)A plan for incidental medical and dental care shall be developed...(1)The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. This requirement was not met as evidenced by:
1
2
3
4
5
6
7
The licensee and administrator agreed to submit proof of terminiation of previous Administrator, and submit the administrator's schedule
8
9
10
11
12
13
14
Based on interview and record review the facility did not develop a plan to address R1's care needs or arrange for the timely medical attention of R1's feet. This poses an immediate. health, safety, or personal rights risk to residents in care.
8
9
10
11
12
13
14
and routine to ensure staff communication, proper notification,care and changes of condition for residents are reported timely by the POC due date.
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: Carolyn Tuba
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE:

DATE: 09/25/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 4