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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 335530171
Report Date: 05/28/2025
Date Signed: 05/28/2025 10:27:42 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/10/2025 and conducted by Evaluator Melody Brown
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20250210145138
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: 121DATE:
05/28/2025
ANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Executive Director Karen RoperTIME COMPLETED:
10:30 AM
ALLEGATION(S):
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Licensee is not providing resident's records to their representative as necessary.
INVESTIGATION FINDINGS:
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On 05/28/2025 at 09:00 AM, Licensing Program Analyst (LPA), Melody Brown, met with Executive Director (ED) Karen Roper at Community Care Licensing Division (CCLD) Adult and Senior Care (ASC) San Bernardino (SB) Regional Office to deliver complaint investigation findings for the above allegation.
LPA Brown explained the purpose of the requested Office Visit to ED Roper.

The investigation was conducted by LPA Melody Brown. The investigation consisted of file review and interviews with relevant parties. The allegation indicates that Licensee is not providing resident's records to their representative as necessary. LPA Brown obtained evidence to corroborate the allegation. During the facility visit in 02/13/2025, Staff #1 (S1) reported to LPA Brown that S1 did not receive a records request from Resident #1 (R1) representative. Records review indicated that R1 records request was sent to the facility in 01/16/2025 via email with R1 Authorized Representative authorization and R1 records were not obtained. In addition, investigations revealed that R1 records request was sent again in 02/04/2025 with attached Access to facilities and Records and ***Continuation in LIC9099C***
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 05/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2025
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-20250210145138
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME: WILDOMAR SENIOR ASSISTED LIVING
FACILITY NUMBER: 335530171
VISIT DATE: 05/28/2025
NARRATIVE
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the request has not been honored as well.

Based on the information and interviews gathered, the allegation Licensee is not providing resident's records to their representative as necessary is SUBSTANTIATED. A finding that the complaint is SUBSTANTIATED means that the allegation(s) is valid because the preponderance of the evidence standard has been met. Please see LIC9099D for deficiency cited.

An exit interview was conducted where this report (LIC9099), LIC9099D and Appeal Rights were discussed, and a copies were provided to ED Karen Roper at the conclusion of the visit.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 05/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 56-AS-20250210145138
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: WILDOMAR SENIOR ASSISTED LIVING
FACILITY NUMBER: 335530171
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/28/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/03/2025
Section Cited
CCR
87506(c)(1)
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87506 Resident Records (c) All information and records obtained from or regarding residents...(1)The Licensee... 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. This requirement was not met as evidenced by:
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Licensee stated to train all staff on CCR 87506(c)(1) and submit proof of all staff training log to LPA Brown by the Plan of Correction (POC) due date.
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Based on interviews and records review, the Licensee did not comply with the section cited above by not ensuring that Resident #1 (R1) records were provided to R1 Authorized Representative which poses a potential health, safety and personal rights risk to resident 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: Melody Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 05/28/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3