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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603444
Report Date: 04/11/2025
Date Signed: 04/11/2025 01:10:09 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
02/12/2025 and conducted by Evaluator Elizabeth Irra
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20250212113650
FACILITY NAME:EVEREST AT WALNUT VALLEY SENIOR LIVINGFACILITY NUMBER:
198603444
ADMINISTRATOR:MATSUMOTO,CHRISTINAFACILITY TYPE:
740
ADDRESS:19850 E COLIMA ROADTELEPHONE:
(909) 595-5030
CITY:WALNUTSTATE: CAZIP CODE:
91789
CAPACITY:120CENSUS: 93DATE:
04/11/2025
UNANNOUNCEDTIME BEGAN:
08:15 AM
MET WITH:Christina MatsumotoTIME COMPLETED:
01:15 PM
ALLEGATION(S):
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Staff mismanaging resident’s medication(s).
Staff misplaced resident’s medication(s).
Staff billing resident for medication not administered.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Elizabeth Irra conducted a subsequent visit to investigate the above allegations. LPA met with Christina Matsumoto/S-1 and discussed the purpose of today's visit.

During the initial visit (02/18/25), LPA obtained a copy of the staff and resident rosters, interviewed Staff #1 (S-1)/Facility Administrator and reviewed Resident #1 (R-1) file and obtained relevant documentation. During the course of this investigation, LPA also interviewed Staff #2 (S-2) through Staff #4 (S-4) and Resident #1 (R-1) through Resident #7 (R-7).

Refer to LIC 9099C for the continuation of this report.
Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Elizabeth Irra
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2025
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-20250212113650
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: 04/11/2025
NARRATIVE
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Staff mismanaging resident’s medication(s). It has been alleged that staff are mismanaging R-1’s sodium chloride medication. Staff interviews revealed that staff made numerous attempts to contact R-1’s physician to have R-1’s sodium chloride medication discontinued (per R-1’s authorized representative request) and were unsuccessful. Interviewed staff indicated that R-1’s authorized representative was successful in reaching R-1’s physician and obtained an order to discontinue the sodium chloride medication in which facility staff discontinued administering since receiving this new order (discontinued on 01/24/25). Resident interviews revealed that staff do not mismanage medications. Interviewed residents indicated that staff provide their medication as prescribed. Interviewed residents indicated they have not heard anyone complain nor have any concerns pertaining to this matter. Interviews do not corroborate this allegation.

Staff misplaced resident’s medication(s). It has been alleged that Atenolol medication for R-1 was provided to a med tech “last September” and it was misplaced. Interviewed staff indicated that staff do not misplace residents’ medications. Staff interviews revealed that Atenolol medication for R-1 was not received from R-1’s authorized representative. Resident interviews revealed that staff do not misplace residents’ medications. Interviewed residents indicated they have not heard anyone complain nor have any concerns pertaining to this matter. Interviews do not corroborate this allegation.

Staff billing resident for medication not administered. It has been alleged that staff are billing R-1 for medication that is not administered. Interviewed staff indicated that the staff nor this facility are not involved with billing for medications as the billing comes directly from the pharmacy. Interviewed staff indicated that residents and/or authorized representatives are responsible for paying any medical/pharmacy co-pays directly to those entities and not to this facility. Interviewed staff indicated that the medication billed and received by the pharmacy is administered as prescribed. Staff interviews revealed they have not received any complaints pertaining to this matter. Resident interviews revealed that residents pay their own co-pays for medical and medication services directly to the providers and not this facility. Interviewed residents indicated they have not heard anyone complain nor have any concerns pertaining to this matter. Interviews do not corroborate this allegation.

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.

Exit interview conducted, appeals rights and a copy of this report was provided to Christina Matsumoto/S-1/Administrator.

NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Elizabeth Irra
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2025
LIC9099 (FAS) - (06/04)
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