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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 335530171
Report Date: 05/05/2025
Date Signed: 05/05/2025 12:51:36 PM

Substantiated


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
04/30/2025 and conducted by Evaluator Raquel Hernandez
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20250430111009
FACILITY NAME:WILDOMAR SENIOR ASSISTED LIVINGFACILITY NUMBER:
335530171
ADMINISTRATOR:YOUSEFIAN, ROSEFACILITY TYPE:
740
ADDRESS:32365 SOUTH PASADENA STTELEPHONE:
(323) 902-6000
CITY:WILDOMARSTATE: CAZIP CODE:
92595
CAPACITY:200CENSUS: 119DATE:
05/05/2025
UNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Administrator Karen RoperTIME COMPLETED:
01:00 PM
ALLEGATION(S):
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Licensee is not providing resident's records to their representative as necessary.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Raquel Hernandez conducted an unannounced visit for the delievering findings of allegation listed above. LPA met with Administrator Karen Roper and explained today's visit. Investigation consisted of request of documentation.

For the allegation, Licensee is not providing resident's records to their representative as necessary.

LPA Hernandez spoke with Administrator Karen Ruper who stated facility did not receive request from authorized reprensentative until a later date then one stated. LPA Hernandez observed resident's representative request of doucmentation letter which stated request of resident documentation was requested via fax with date 02/07/2025. Administrator Karen stated documentation will be sent over to legal team and resident representative today 05/05/2025.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Raquel Hernandez
LICENSING EVALUATOR SIGNATURE:

DATE: 05/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2025
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 56-AS-20250430111009
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: 05/05/2025
NARRATIVE
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Based on the evidence gathered during today’s investigation, the one (1) allegation listed above are deemed SUBSTANTIATED. A finding that the complaints are SUBSTANTIATED means that the allegations are valid because the preponderance of evidence the standard has been met.

During today’s visit, one (1) deficiency were cited per Title 22, Division 6, of the California Code of Regulations.

An exit interview was conducted, and this report (LIC9099) and LIC9099D was discussed and provided to Administrator Karen Roper, along with a copy of the appeal rights.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Raquel Hernandez
LICENSING EVALUATOR SIGNATURE:

DATE: 05/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3
Control Number 56-AS-20250430111009
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/05/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/09/2025
Section Cited
CCR
87506(c)(1)
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 87506 Resident Records (c).. (1) The licensee and all employees shall reveal or make available confidential information only upon the resident's written consent or that of his designated representative.
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Licensee stated to submit resident records to resident representative today 05/05/2025.
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Based on observation and record review, the licensee did not comply with section cited above by not ensuring residents records are provided to residents representative, which poses a potential health, safety, and personal rights risks to those 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: Raquel Hernandez
LICENSING EVALUATOR SIGNATURE:

DATE: 05/05/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3