331800223-5-13-2025-18-AS-APAO-DGVMHD-20250521093721

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 331800223
Report Date: 05/12/2025
Date Signed: 05/13/2025 12:42:46 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
03/11/2025 and conducted by Evaluator Venus Mixson

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20250311133731

FACILITY NAME:	YORKSHIRE VILLAGE		FACILITY NUMBER:	331800223
ADMINISTRATOR:	TERESA MAPILIS		FACILITY TYPE:	740
ADDRESS:	26933 CORNELL ST		TELEPHONE:	(951) 658-1068
CITY:	HEMET	STATE: CA	ZIP CODE:	92544
CAPACITY:	100	CENSUS: 87	DATE:	05/12/2025
		UNANNOUNCED	TIME BEGAN:	12:25 PM
MET WITH:	ADMINISTRATOR, TERESA M		TIME COMPLETED:	12:45 PM

ALLEGATION(S):

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Staff mismanaged resident's medication
Staff restrained resident in care

INVESTIGATION FINDINGS:

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On May 13, 2025, Licensing Program Analyst (LPA), Venus Mixson arrived at the facility unannounced and met with Teresa Mapilis, Administrator. LPA explained the reason for the visit was to provide findings for the complaint investigation.

On March 11, 2025, Community Care Licensing received a complaint alleging staff mismanaged resident’s medication and staff restrained resident in care. During the investigation, LPA conducted interviews, record reviews, and made observations. It was reported facility staff was giving Resident 300 mg of a medication when their physician's order stated 200mg. Additionally it was reported on March 7, 2025, a Geri chair was observed to be pushed up against Resident’s bed to deter Resident from exiting or falling out of the bed.
Regarding the allegation staff mismanaged resident’s medication, it was reported facility staff was giving Resident 300 mg of a medication when Resident’s Physician's Order prescribed only 200mg. Information obtained from interview with Administrator stated Resident #1 was receiving hospice services through Hope. Administrator stated all of Resident #1’s medication was prescribed and ordered through their hospice services. It was further explained Resident’s medication was in bubble packs that were identified as morning and evening medication and it was only one pill for each distribution. Administrator did state that Resident had a previous prescription for 200 mg, but on March 8, 2025, the prescription was discontinued.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Venus Mixson
LICENSING EVALUATOR SIGNATURE:	DATE: 05/12/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2025

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 3

Control Number 18-AS-20250311133731

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: YORKSHIRE VILLAGE	FACILITY NUMBER: 331800223
	VISIT DATE: 05/12/2025

NARRATIVE

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Administrator stated a new prescription of 100 mg was issued and was ordered to start on March 9, 2025. It was advised that Resident #1 died on March 9, 2025. Information obtained from interviews with additional staff advised Resident’s Physician’s Order for the 200mg was 14 days and then a new prescription was initiated. Staff indicated there were no concerns advised regarding the mismanagement of Resident #1’s medication. Information obtained from interviews with additional staff indicated there was no information provided regarding R1’s medications being mismanaged. Information obtained from interviews with Hospice Nurses advised the medications were provided to the facility labeled and in bubble packs. It was confirmed Resident was prescribed 200 mg. Additional information obtained indicated when Hospice Nurses are not available, facility staff will distribute medication. Interviews with additional residents did not indicate any issues or concerns regarding medication management. A review of Resident #1’s Physician Order dated February 11, 2025 indicated Resident was prescribed 200 mg of the medication for 14 days and then a prescription of 100 mg was initiated. Medication Administration Record dated from March 1 to March 31, 2025 indicated Resident was prescribed 200 mg of the medication until March 8, 2025. No additional documentation is recorded due to Resident’s death. The last dosage of 200 mg was given on March 8, 2025. A review of additional records revealed there were no documentation of errors or missed medications. Due to the passing of Resident, LPA was unable to obtain additional information regarding the distribution of medication. LPA also attempted to interview additional witnesses regarding the allegations, but was unsuccessful in their attempts.

Regarding the allegation that staff restrained resident in care. Additionally, it was reported resident was slouched in the bed with their head against bed. Information obtained from interview with Administrator denied this allegation. Administrator stated Resident #1 does require total assistance for transferring from chair to bed.

SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Venus Mixson
LICENSING EVALUATOR SIGNATURE:	DATE: 05/12/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2025

LIC9099 (FAS) - (06/04)

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Control Number 18-AS-20250311133731

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: YORKSHIRE VILLAGE	FACILITY NUMBER: 331800223
	VISIT DATE: 05/12/2025

NARRATIVE

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Administrator stated staff are aware and trained to assist in transfer. Interviews with additional staff acknowledged Resident #1 was a total assist. It was indicated Resident #1 was on Hospice and required a hospital bed with rails. Staff denied utilizing a Geri chair to keep Resident #1 restrained. Interviews with additional residents indicated staff do not use Geri Chair to restrain residents and there are no additional concerns. LPA was unable to interview Resident #1 due to their death.

Based on interviews, record reviews, and observations, the allegations that staff mismanaged resident’s medication and staff restrained resident in care may have happened or is valid, but there is not a preponderance of the evidence to prove the alleged violations did or did not occur. Therefore, the allegations have been determined unsubstantiated.

An exit interview was conducted and a copy of this report was provided to Administrator, Teresa Mapilis.

SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Venus Mixson
LICENSING EVALUATOR SIGNATURE:	DATE: 05/12/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2025

LIC9099 (FAS) - (06/04)

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