335530171-7-8-2026-56-AS-KCLS-DWEN39-20260728100559

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 335530171
Report Date: 06/18/2025
Date Signed: 07/08/2026 02:40:07 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO 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
06/13/2025 and conducted by Evaluator Eldin Serrano

PUBLIC

COMPLAINT CONTROL NUMBER: 56-AS-20250613162316

FACILITY NAME:	WILDOMAR SENIOR ASSISTED LIVING		FACILITY NUMBER:	335530171
ADMINISTRATOR:	KAREN ROPER		FACILITY TYPE:	740
ADDRESS:	32365 SOUTH PASADENA ST		TELEPHONE:	(323) 902-6000
CITY:	WILDOMAR	STATE: CA	ZIP CODE:	92595
CAPACITY:	200	CENSUS: 127	DATE:	06/18/2025
		UNANNOUNCED	TIME BEGAN:	08:45 AM
MET WITH:	Karen Roper, Executive Director		TIME COMPLETED:	11:45 AM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff neglect/lack of supervision resulting in a resident being physically abused.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

On June 18, 2025, at 8:45 a.m., Licensing Program Analyst (LPA) Eldin Serrano, conducted an unannounced visit to investigate and deliver the findings for the above allegation. LPA met with Executive Director Karen Roper and explained the purpose of the visit.

The investigation included interviews with facility staff and residents, a review of facility records, resident records, and facility procedures, as well as observations made during the visit.

On June 12, 2025, there was a physical altercation between Resident 1 (R1) and Resident 2 (R2) while they were in the room they shared. Interviews revealed that facility staff responded to R1's room and found R1 sitting on the bed in need of medical assistance. Facility staff immediately contacted 911, and paramedics and law enforcement responded to assess both residents. R1 was transported to the hospital due to injuries sustained during the incident, and R2 was detained by law enforcement.

*** Continuation in LIC9099C ***

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Eldin Serrano
LICENSING EVALUATOR SIGNATURE:	DATE: 06/18/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2025

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 2

Control Number 56-AS-20250613162316

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: WILDOMAR SENIOR ASSISTED LIVING	FACILITY NUMBER: 335530171
	VISIT DATE: 06/18/2025

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

During the Department's investigation, LPA requested and reviewed facility records, the police report, resident records, and the residents' most recent appraisals. R1 has a diagnosis of dementia. R2 did not have a documented diagnosis of cognitive impairment. The records reviewed did not identify a history of aggressive or assaultive behavior for either R1 or R2. R1 and R2 had been roommates for more than one year, and there were no prior Special Incident Reports (SIRs) or other documentation indicating previous physical altercations involving either resident.

During interviews, five (5) residents and four (4) staff members stated they had never witnessed physical altercations between residents at the facility. One staff member reported that the allegation mentioned was the first physical altercation to occur at the facility and stated that staff immediately intervened to separate the residents. Staff consistently stated that when verbal disagreements occur between residents, staff intervene by redirecting the residents and attempting to de-escalate the situation. The facility also provided its written policies and procedures regarding resident behavior management.

The investigation did not reveal evidence that the facility had prior knowledge that R2 exhibited aggressive behaviors toward residents requiring additional supervision before the incident. No documentation reviewed identified a pattern of aggressive behavior or other information indicating the incident was foreseeable.

R1 and R2 were not interviewed because R1 remained hospitalized during the investigation, and R2 remained in police custody. Therefore, neither resident was available for interview.

Based on interviews, record reviews, and other information obtained during the investigation, there is insufficient evidence to corroborate that staff neglect/lack of supervision resulted in a resident being physically abused. The evidence obtained did not establish that the residents required additional preventive interventions or that staff failed to respond appropriately once the altercation occurred. Therefore, the allegation is Unsubstantiated.

An exit interview was conducted with Regional Director Kenya Carlton.The amended LIC 9099 and LIC 9099C were discussed and provided.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Eldin Serrano
LICENSING EVALUATOR SIGNATURE:	DATE: 06/18/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 2