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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331800223
Report Date: 07/23/2026
Date Signed: 07/23/2026 02:13:05 PM

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
04/02/2025 and conducted by Evaluator Seo Jeon
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20250402120100
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: 85DATE:
07/23/2026
UNANNOUNCEDTIME BEGAN:
12:35 PM
MET WITH:Bianey Sandoval, Medtech ManagerTIME COMPLETED:
02:45 PM
ALLEGATION(S):
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Resident sustained unexplained injuries while in care
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPA) Seo Jeon and Janira Arreola conducted an unannounced visit to the facility to deliver findings of the above allegation. LPA met with Bianey Sandoval, Medtech Manager, and informed them of the purpose of the LPA’s visit. The Department’s investigation involved interviews with staff and residents and review of records.

On April 2, 2025, Community Care Licensing (The Department) received a complaint report with the following allegation. It was alleged that resident sustained unexplained injuries while in care. Information received indicated that Resident #1 (R1) was observed with multiple bruises from unknown sources.

The Department conducted record reviews. R1 was admitted to the facility in June 2022. R1 required staff assistance due to their physical and cognitive condition. R1 also required occasional staff assistance due to their disruptive and aggressive behavior. Continuned on LIC9099-C....
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Seo Jeon
LICENSING EVALUATOR SIGNATURE:

DATE: 07/23/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/23/2026
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 3
Control Number 18-AS-20250402120100
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: 07/23/2026
NARRATIVE
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R1 had history of falls from December 2024 through July 2025. R1 had total of seven (7) reported falls during that time. R1 was sent to Hospital #1 on March 31, 2025, by R1’s physician’s order for altered mental status and frequent falls. R1 was hospitalized until they were discharged to a skilled nursing facility on April 23, 2025. R1 was sent to Hospital #2 after being found unconscious on August 10, 2025. R1 passed away on August 10, 2025, while under hospice care.

The Department’s review of medical records from Hospital #1 revealed that R1 was observed with bruises on left upper hip, right lower hip, and multiple bruises in upper and lower extremities in various stages of healing. R1 was also noted to be confused, not able to follow commands, frequently trying to get out of bed, pulling on IV lines, agitation, yelling and screaming. Those conditions required R1 to be put on soft restraints on upper and lower extremities. R1 remained restrained until they were discharged on April 23, 2025.

The Department’s review of records revealed that staff did not conduct reassessment and update care plans after seven (7) recorded falls. Five (5) out of those (7) falls occurred in March 2025. R1’s bruises observed by medical staff at Hospital #1 were consistent with those five (5) falls that occurred in March 2025. Even after those falls, staff did not maintain updated assessments and care plans reflecting R1’s declining condition and increased fall risks.

Based on records review, the evidence found during the Department’s investigation met the preponderance of evidence standard. Therefore, this allegation is substantiated.

A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. A citation was issued.

An exit interview was conducted where a copy of this report was provided, along with a copy of LIC9099-D and Appeal Rights.

SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Seo Jeon
LICENSING EVALUATOR SIGNATURE:

DATE: 07/23/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/23/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 18-AS-20250402120100
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: 07/23/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/06/2026
Section Cited
CCR
87463(a)
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87463 Reappraisals, (a)The pre-admission appraisal, as specified in Section 87457..., shall be updated in writing as frequently as necessary..., the updated pre-admission..., the reappraisal.
This requirement was not met as evidenced by:
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Medtech manager agreed to discuss the matter with the licensee and the administrator and send meeting notes involving resident wellness coordinator who is responsible for reassessment to LPA by the POC due date.
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Based on records review, staff did not conduct reassessment on Resident #1 after multiple falls occurred in one month in 2025. This posed potential health and safety risks to residents in care.
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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.
SUPERVISOR'S NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Seo Jeon
LICENSING EVALUATOR SIGNATURE:

DATE: 07/23/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/23/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 3