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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331800223
Report Date: 06/30/2026
Date Signed: 07/01/2026 07:54:46 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
05/28/2026 and conducted by Evaluator Valerie Flores
COMPLAINT CONTROL NUMBER: 18-AS-20260528162825
FACILITY NAME:YORKSHIRE VILLAGEFACILITY NUMBER:
331800223
ADMINISTRATOR:TERESA MAPILISFACILITY TYPE:
740
ADDRESS:26933 CORNELL STTELEPHONE:
(951) 658-1068
CITY:HEMETSTATE: CAZIP CODE:
92544
CAPACITY:100CENSUS: 90DATE:
06/30/2026
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Medication Technician Manager Bianey SandovalTIME COMPLETED:
03:45 PM
ALLEGATION(S):
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Staff did not seek medical attention for resident’s injury
INVESTIGATION FINDINGS:
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On 6/30/2026, Licensing Program Analyst (LPA) Valerie Flores conducted an unannounced visit to the facility for the purpose of delivering the investigative findings into the allegations listed above. LPA Flores met with Medication Technician Manager Bianey Sandoval and explained the purpose of the visit. The investigation is summarized as follows:

On 5/28/2026, Community Care Licensing received information alleging staff did not seek medical attention for Resident #1’s (R1’s) after R1 sustained a hematoma to the back of the head as a result of a fall. Interviews conducted with (2) two out of (4) four staff reported that when R1 fell, Staff #1 (S1) contacted emergency services. Interview with S1 reported that they contacted emergency services on their personal cell phone but no longer has the call log showing a call was made on 5/27/2026. S1 reports that it took emergency services 20 minutes to respond the incident.

(Continue to LIC9099C)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Valerie Flores
LICENSING EVALUATOR SIGNATURE:

DATE: 06/30/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/30/2026
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 6
Control Number 18-AS-20260528162825
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: YORKSHIRE VILLAGE
FACILITY NUMBER: 331800223
VISIT DATE: 06/30/2026
NARRATIVE
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(Continuation from LIC9099)

An interview conducted with Staff #3 (S3) reports that they do not recall emergency services being contacted. S3 stated that due to R1 receiving hospice care services, Yorkshire staff were instructed by Yorkshire management to contact the hospice provider if any incidents occur with a resident. Additional interviews conducted with S1 and Staff #2 (S2) confirmed that staff are instructed to contact the hospice provider if the resident is receiving hospice services as was alleged through past experience, emergency personnel have informed Yorkshire staff that the emergency services need prior approval to assist residents who are receiving hospice services. An interview was attempted with Staff #4 (S4) but was unsuccessful as S4 did not recall details of the incident dating on 5/27/2026. Interviews with (3) three of (4) four staff report R1 was not transported to the hospital as a result of R1’s injuries. LPA attempted (2) two additional staff interviews for staff that were reportedly present to the incident. LPA Flores concluded the interview attempts as the attempts were unsuccessful. An interview conducted with Relevant Party #1 (RP1) reports that they received a telephone call informing them that R1 experienced a fall and was requiring an evaluation. RP1 reports that the call was received at approximately 10AM on 5/27/2026 and RP1 did not arrive at the facility until approximately 1PM. RP1 explained that they have prior experience working at a Residential Care Facility for the Elderly and believed that the facility should have contacted emergency services regardless if R1 was receiving hospice care services. RP1 described the hematoma on the back of R1’s head to be the size of a golf ball and explained that an injury of that size at R1’s age can come with underlying issues that would require emergency services. A records request was submitted to the California Department of Forestry and Fire Protection for the incident dating on 5/27/2026. LPA Flores was informed that there are no records matching the R1’s name for that date.

Therefore, the allegation of staff did not seek medical attention for resident’s injury is deemed substantiated. A finding that the complaint is SUBSTANTIATED means that the allegation is valid as the preponderance of the evidence standard has been met. Health and Safety Code is being cited on the attached LIC9099D.

An exit interview was conducted and a copy of the LIC9099, LIC9099C, LIC9099D, and appeal rights were provided to Medication Technician Manager Bianey Sandoval.
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Valerie Flores
LICENSING EVALUATOR SIGNATURE:

DATE: 06/30/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/30/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 18-AS-20260528162825
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: YORKSHIRE VILLAGE
FACILITY NUMBER: 331800223
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/30/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/14/2026
Section Cited
CCR
87469(c)(3)
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(c)If a resident who has an advance directive… facility staff shall do one of the following: (3) is experiencing a life-threatening emergency …directly related to the expected course of the resident’s terminal illness, the facility may immediately notify the resident’s hospice agency in lieu of calling
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All staff will complete an outside vendor training will be conducted covering how to determine a life threatening emergency requiring emegency response (9-1-1). Proof will be submitted to LPA via email by Close of Business on 7/14/2026.
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emergency response (9-1-1). For emergencies not directly related … staff shall immediately telephone emergency response (9-1-1). This requirement was not met with evidence by: Emergency services were not contacted for R1 after R1 sustained a hematoma as a result of a fall.
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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: Anthony Perez
LICENSING EVALUATOR NAME: Valerie Flores
LICENSING EVALUATOR SIGNATURE:

DATE: 06/30/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/30/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 6
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
05/28/2026 and conducted by Evaluator Valerie Flores
COMPLAINT CONTROL NUMBER: 18-AS-20260528162825

FACILITY NAME:YORKSHIRE VILLAGEFACILITY NUMBER:
331800223
ADMINISTRATOR:TERESA MAPILISFACILITY TYPE:
740
ADDRESS:26933 CORNELL STTELEPHONE:
(951) 658-1068
CITY:HEMETSTATE: CAZIP CODE:
92544
CAPACITY:100CENSUS: DATE:
06/30/2026
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Medication Technician Manager Bianey SandovalTIME COMPLETED:
03:45 PM
ALLEGATION(S):
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Staff provided an unauthorized medication to a resident
Resident forced on hospice due to insufficient staffing
INVESTIGATION FINDINGS:
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On 6/30/2026, Licensing Program Analyst (LPA) Valerie Flores conducted an unannounced visit to the facility for the purpose of delivering the complaint investigative findings into the allegations listed above. LPA Flores met with Medication Technician Manager Bianey Sandoval and explained the purpose of the visit. The investigation is summarized as follows:

On 5/28/2026, Community Care Licensing (CCL) received information alleging staff provided an unauthorized medication to Resident #1 (R1). Interviews conducted with R1’s responsible party reports that Medication #1 (M1) was prescribed to R1 in the past and was discontinued per the request of R1’s responsible person as they observed significant changes to R1’s behavior. R1’s responsible person is unsure when the medication was first prescribed and when the medication was discontinued.

(Continue to LIC9099AC)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Valerie Flores
LICENSING EVALUATOR SIGNATURE:

DATE: 06/30/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/30/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 18-AS-20260528162825
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: YORKSHIRE VILLAGE
FACILITY NUMBER: 331800223
VISIT DATE: 06/30/2026
NARRATIVE
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(Continuation from LIC9099A)

R1’s responsible person reports that they were made aware of R1 receiving M1 by receiving a text message from R1’s hospice care provider explaining that R1 experienced a fall and M1 was administered for pain relief. R1’s responsible person reports that the staff did not contact R1’s responsible person to approve of M1 being administered to R1. R1’s responsible person reports that staff nor the prescribing physician never contacted R1’s responsible person explaining that M1 was being re-prescribed to R1. An interview conducted with Staff #1 (S1) reports that R1 was prescribed M1 by R1’s designated physician. S1 reports that M1 was previously discontinued for a brief period some time last year but does not know exactly when and how long M1 was discontinued. S1 reports that when a medication is re-prescribed at that level, it is the physicians responsibility to contact the resident’s responsible person advising the responsible person about the medication changes. S1 reports that they are unsure if there was a telephone between R1’s responsible person and the prescribing physician as they were not privy to the telephone call. A copy of a physician order was received for R1 details M1’s start date as 4/16/2025. LPA Flores contacted the prescribing physicians office to obtain clarification the prescription of M1 but an interview with an office representative reports that they do not have any records of there being an active order for M1. LPA Flores conducted serval attempt to interview Relevant Party #1 (RP1) and Relevant Party #2 (RP2) but attempts were unsuccessful.

Additional information alleged that R1 was forced into enrolling with hospice services due to insufficient staffing. An interview conducted with R1 responsible person reports that they were not forced into enrolling with hospice services but feels tricked into hospice services instead. R1’s responsible person reports that R1 has experienced an increase in falls and was approached by the Administrator. R1’s responsible person reports that the Administrator stated that hospice can assist with providing additional care such as fall prevention and decrease the number of times R1 would be transported to the hospital. R1’s responsible person reports that at the time they believed hospice was a good choice as it may decrease any potential trauma R1 may endure by being transported to and from the doctors office. R1’s responsible person stated that they enrolled R1 into hospice and later did research on what hospice services are. R1 responsible person reports that they learned that hospice was an end-of-life treatment service and stated that R1 is nowhere near end-of-life. R1 responsible person reports that they removed R1 from receiving hospice care services only after a week. R1 responsible person reports that they were not specifically instructed to enroll with any specific hospice but were also not given suggestions other than the hospice care agency R1 was enrolled in.

(Continue to LIC9099AC2)
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Valerie Flores
LICENSING EVALUATOR SIGNATURE:

DATE: 06/30/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/30/2026
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 18-AS-20260528162825
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: YORKSHIRE VILLAGE
FACILITY NUMBER: 331800223
VISIT DATE: 06/30/2026
NARRATIVE
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(Continuation from LIC9099AC)

LPA attempted to speak with Relevant Party #3 (RP3) but attempts to interview RP3 were unsuccessful.

Therefore, the allegations of staff provided an unauthorized medication to a resident and resident forced on hospice due to insufficient staffing are deemed unsubstantied. A finding that the complaint is UNSUBSTANTIATED means 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 allegations are unsubstantiated at this time.

An exit interview was conducted, and a copy of this report was provided to Medication Technician Manager Bianey Sandoval.
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Valerie Flores
LICENSING EVALUATOR SIGNATURE:

DATE: 06/30/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/30/2026
LIC9099 (FAS) - (06/04)
Page: 6 of 6