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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331800490
Report Date: 06/18/2026
Date Signed: 06/18/2026 04:23:41 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 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
02/18/2026 and conducted by Evaluator Mary Rico
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20260218153924
FACILITY NAME:VILLA DESCANSO SENIOR LIVINGFACILITY NUMBER:
331800490
ADMINISTRATOR:TORRES, GABRIELAFACILITY TYPE:
740
ADDRESS:6683 LEANNE STREETTELEPHONE:
(951) 407-1501
CITY:EASTVALESTATE: CAZIP CODE:
91752
CAPACITY:6CENSUS: 6DATE:
06/18/2026
UNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Staff Valerie RutherfordTIME COMPLETED:
04:45 PM
ALLEGATION(S):
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Medication is not being dispensed properly.
Staff are not reporting incidents.
Facility is not in good repair.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Mary Rico conducted an unannounced visit to investigate and deliver findings on the allegations listed above. LPA met with staff member Valerie Rutherford and explained the purpose of the visit. The licensee, Gabriela Torres, was contacted. LPA Rico was unable to leave a voicemail as the inbox was full.The investigation consisted of staff interviews, resident interviews, and a review of facility records.

For the allegation, Medication is not being dispensed properly: During staff interviews, S1 admitted that there was a medication error on their Medication Administration Record (MAR). During a medication audit, LPA Rico observed that staff were not following R2’s medication orders. R2’s medication order states the medication should be administered five days out of seven; however, staff were documenting that the medication was given every day. In addition, LPA Rico observed that medications had been transferred into another container. Medications must remain in their original packaging.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Mary Rico
LICENSING EVALUATOR SIGNATURE:

DATE: 06/18/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2026
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 56-AS-20260218153924
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: VILLA DESCANSO SENIOR LIVING
FACILITY NUMBER: 331800490
VISIT DATE: 06/18/2026
NARRATIVE
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For the allegation, Staff are not reporting incidents: During staff interviews, S1 informed LPA that they have been submitting incident reports to Community Care Licensing. However, based on record review, LPA Rico observed that the facility has not been submitting incident reports to Community Care Licensing. The last incident report submitted to the Department was in 2020.

For the allegation, Facility is not in good repair: During staff interviews, 2 out of 3 staff stated that the facility is not in good repair. During resident interviews, 2 out of 3 residents also stated that the facility is not in good repair. During the facility tour, LPA Rico observed that the kitchen stove had missing knobs and the dishwasher did not turn on or off. In addition, LPA Rico observed S2 using a lighter to turn on the stove.

Based on the evidence gathered during today’s investigation, the three (3) allegations listed above are deemed SUBSTANTIATED. A finding of SUBSTANTIATED means the allegations are valid because the preponderance of evidence standard has been met. During today’s visit, three (3) deficiencies were cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted, and this report (LIC9099) and LIC9099D were discussed with and provided to staff Valerie Rutherford, along with a copy of the appeal rights.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Mary Rico
LICENSING EVALUATOR SIGNATURE:

DATE: 06/18/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 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
02/18/2026 and conducted by Evaluator Mary Rico
COMPLAINT CONTROL NUMBER: 56-AS-20260218153924

FACILITY NAME:VILLA DESCANSO SENIOR LIVINGFACILITY NUMBER:
331800490
ADMINISTRATOR:TORRES, GABRIELAFACILITY TYPE:
740
ADDRESS:6683 LEANNE STREETTELEPHONE:
(951) 407-1501
CITY:EASTVALESTATE: CAZIP CODE:
91752
CAPACITY:6CENSUS: 6DATE:
06/18/2026
UNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Staff - Valerie RutherfordTIME COMPLETED:
04:45 PM
ALLEGATION(S):
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Staff are sleeping in common areas.
Staff assist resident in a rough manner.
Due to staff neglect, resident was left on the floor for hours
Staff are violating resident's personal rights.
Staff are injecting needles.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Mary Rico conducted an unannounced visit to deliver findings regarding the allegations listed above. LPA met with staff member Valerie Rutherford and explained the purpose of the visit. The licensee, Gabriela Torres, was contacted. LPA Rico was unable to leave a voicemail as the inbox was full.The investigation consisted of staff interviews, resident interviews, and a review of facility records.

For the allegation Staff are sleeping in common areas: During staff interviews, 3 out of 3 staff stated that staff are not sleeping in common areas. During resident interviews, 2 out of 3 residents stated they have not seen staff sleeping in common areas. During the facility tour, LPA did not observe any mattresses or bedding in common areas.

For the allegation Staff assist residents in a rough manner: During staff interviews, 3 out of 3 staff denied assisting residents in a rough manner. During resident interviews, 3 out of 3 residents stated they have not been assisted in a rough manner.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Mary Rico
LICENSING EVALUATOR SIGNATURE:

DATE: 06/18/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 56-AS-20260218153924
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: VILLA DESCANSO SENIOR LIVING
FACILITY NUMBER: 331800490
VISIT DATE: 06/18/2026
NARRATIVE
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For the allegation Due to staff neglect, a resident was left on the floor for hours: During staff interviews, 3 out of 3 staff stated no residents have been left on the floor for hours. During resident interviews, 3 out of 3 residents stated they have not been left on the floor for hours.

For the allegation Staff are violating residents’ personal rights: During staff interviews, 3 out of 3 staff stated they have not violated residents’ personal rights. During resident interviews, 3 out of 3 residents stated staff have not violated their personal rights.

For the allegation Staff are injecting needles: During staff interviews, 3 out of 3 staff stated they are not injecting needles. Staff also indicated that Resident #1 (R1) administers their own insulin. During resident interviews, R1 confirmed they handle their own insulin. A review of R1’s Physician’s Report indicated that R1 is able to self-administer insulin.

Based on the evidence gathered during the investigation, the five (5) allegations listed above are deemed UNSUBSTANTIATED. A finding of UNSUBSTANTIATED means that although the allegations may have happened or may be valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur.

During today’s visit, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted, and this report (LIC9099) was discussed with and provided to Administrator Crystal Cortez.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Mary Rico
LICENSING EVALUATOR SIGNATURE:

DATE: 06/18/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2026
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 56-AS-20260218153924
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: VILLA DESCANSO SENIOR LIVING
FACILITY NUMBER: 331800490
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/18/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/19/2026
Section Cited
CCR
87465(h)(1)
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87465(h)(5)Incidental Medical and Dental Care The following requirements shall apply to medications which are centrally stored:(5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers.
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The licensee stated they will have an all staff medication training. A copy will provided to LPA Rico.
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This requirement was not met as evidenced by;Based on interviews and records review (R2) medication was transfer to a different container. This posed an immediate risk to residents in care.
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POC due date 6/19/2026
Type A
06/19/2026
Section Cited
CCR
87211(a)(1)
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87211(a)(1) Reporting Requirements.. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case.
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The licensee stated they will complete a reporting requirement training. A copy will be provided to LPA Rico.
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This requirement was not met as evidenced by;Based on interviews and records review that licensee has not reported incidents to Community Care Licensing. This posed an immediate risk 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.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Mary Rico
LICENSING EVALUATOR SIGNATURE:

DATE: 06/18/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2026
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 56-AS-20260218153924
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: VILLA DESCANSO SENIOR LIVING
FACILITY NUMBER: 331800490
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/18/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/19/2026
Section Cited
CCR
87303(a)
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87303(a) Maintenance and Operation
(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
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The licensee stated they will complete the repairs, and send proof to LPA Rico.
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This requirement was not met as evidenced by;Based on interviews and facility tour, S2 turning on the stove with a lighter, stove missing knobs and dishewasher out of service. This posed an immediate risk to residents in care.
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POC dute date 6/19/2026
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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: Efren Malagon
LICENSING EVALUATOR NAME: Mary Rico
LICENSING EVALUATOR SIGNATURE:

DATE: 06/18/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2026
LIC9099 (FAS) - (06/04)
Page: 6 of 6