197606472-4-25-2025-28-AS-FFIS-DGF3GB-20250506181403

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197606472
Report Date: 04/25/2025
Date Signed: 04/25/2025 05:59:13 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/21/2025 and conducted by Evaluator Cynthia D Chan

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20250421112759

FACILITY NAME:	BANNER RIDGE COUNTRY HOME		FACILITY NUMBER:	197606472
ADMINISTRATOR:	ELNA C. VILLAFLOR		FACILITY TYPE:	740
ADDRESS:	1006 BANNER RIDGE ROAD		TELEPHONE:	(909) 240-1899
CITY:	DIAMOND BAR	STATE: CA	ZIP CODE:	91765
CAPACITY:	6	CENSUS: 3	DATE:	04/25/2025
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Elna Villaflor, Administrator		TIME COMPLETED:	11:45 AM

ALLEGATION(S):

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Facility did not have a volunteer screened for Tuberculosis prior to providing care and supervision to residents.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Cynthia Chan conducted a complaint investigation regarding the allegation listed above. LPA arrived unannounced and met with Administrator, Elna Villaflor. The reason for the visit was explained.

During the visit today, LPA toured the facility and obtained copies of the resident and staff rosters. LPA also reviewed personnel files and interviewed the administrator and two Staff.

Allegation - Facility did not have a volunteer screened for Tuberculosis prior to providing care and supervision to residents. It is alleged that a volunteer was allowed to work with residents without having a TB clearance. LPA interviewed the administrator and two Staff. Administrator Villaflor stated that staff are required to have a health screening and TB testing when they are hired. She stated that the volunteer (staff #1) worked only a few days sometime in November of 2024. During that time, Staff #1 was sent to get a health screening and TB test, but never returned to work after.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Cynthia D Chan	TELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:	DATE: 04/25/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20250421112759

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: BANNER RIDGE COUNTRY HOME	FACILITY NUMBER: 197606472
	VISIT DATE: 04/25/2025

NARRATIVE

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LPA interviewed an additional two staff. Both staff stated they had gotten a health screening and TB test results before working at the facility. One of the staff stated that Staff #1 was shadowing for about 3 days and stopped working. Staff #1 is no longer working at the facility and was not available for an interview. LPA reviewed current personnel files and observed TB test results and/or chest x-ray at the time of hire. According to Title 22 regulations, 87411(f) "....Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure."

Based on the information gathered, there is insufficient evidence to prove this allegation.
Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore, the allegation is UNSUBSTANTIATED.

An exit interview was conducted with the administrator. A copy of this report, along with the appeal rights, was provided.

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Cynthia D Chan	TELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:	DATE: 04/25/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2025

LIC9099 (FAS) - (06/04)

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