198603444-3-25-2025-28-AS-RORN-DFBNTJ-20250401104448

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603444
Report Date: 03/25/2025
Date Signed: 03/25/2025 03:04:08 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
01/21/2025 and conducted by Evaluator Cynthia D Chan

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20250121093142

FACILITY NAME:	EVEREST AT WALNUT VALLEY SENIOR LIVING		FACILITY NUMBER:	198603444
ADMINISTRATOR:	MATSUMOTO,CHRISTINA		FACILITY TYPE:	740
ADDRESS:	19850 E COLIMA ROAD		TELEPHONE:	(909) 595-5030
CITY:	WALNUT	STATE: CA	ZIP CODE:	91789
CAPACITY:	120	CENSUS: 89	DATE:	03/25/2025
		UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Christina Matsumoto, Administrator		TIME COMPLETED:	02:15 PM

ALLEGATION(S):

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Staff administered felony drugs to resident.
Resident sustained an unexplained head injury.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Cynthia Chan conducted a subsequent visit to continue the investigation on the allegations listed above. LPA met with Administrator, Christina Matsumoto, and explained the purpose of the visit.

On 1/23/25, LPA Chan conducted the initial visit and toured the physical plant. LPA obtained copies of the staff and resident rosters and collected documents for Resident #1. No health and safety concerns were observed. During the visit today, LPA interviewed the Administrator, Staff #1 - #6, and Residents #1 - #8.

The investigation revealed the following:
Allegation – Staff administered felony drugs to resident. It is alleged that Resident #1 (R1) tested positive for cocaine and PCP. LPA obtained medication records for R1 and were reviewed by the Department of Social Services clinical consultant nurse.

Unsubstantiated

Estimated Days of Completion:

NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Cynthia D Chan
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 03/25/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/25/2025

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-20250121093142

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: EVEREST AT WALNUT VALLEY SENIOR LIVING	FACILITY NUMBER: 198603444
	VISIT DATE: 03/25/2025

NARRATIVE

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There was no indication that the medications R1 is taking can produce false positives for cocaine and PCP. However, the hospital medical records showed that R1 was tested positive for felony drugs.
The administrator and Staff were interviewed regarding this allegation. Per the administrator, no felony drugs were given to the resident. Staff interviewed denied giving R1 any illegal drugs and did not notice any signs of drug use. R1 did not behave differently prior to being hospitalized. The med techs stated they only administer medications that are prescribed by the physician, and they are careful in distributing the medications. LPA interviewed R1 who did not remember how resident fell but stated there was no usual item given by staff or visitors. Although R1 tested positive for cocaine and PCP, there is no evidence that the facility staff gave the drugs. Therefore, the allegation is unsubstantiated.

Allegation - Resident sustained an unexplained head injury. LPA interviewed the administrator, Staff, and Residents on this allegation. The facility submitted an incident report to Licensing regarding Resident #1's fall in January. Resident #1 (R1) had a fall on 1/17/25 at approximately 2 a.m. and sustained a head injury. Per the administrator, R1 resided in the assisted living side at the time of the fall. Staff indicated R1 does not like to ask for assistance and would go to the restroom on own. For this reason, staff would ensure that the assistive devices are moved closer to the resident, and nothing is obstructing the walkway. Staff interviewed stated they check on R1 at least every 2 hours and remind resident to press the pendant if assistance is needed. R1’s son was aware of the resident's falls and was in communication with the administrator to move R1 to the memory care unit prior to the last fall. LPA interviewed 8 residents during today’s visit. All the residents stated staff check on them and will assist if needed. Although the resident sustained a head injury, there is no sufficient evidence to show that there is a lack of care/supervision. Therefore, the allegation is unsubstantiated.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED.

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

NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Cynthia D Chan
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 03/25/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/25/2025

LIC9099 (FAS) - (06/04)

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