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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 336424105
Report Date: 04/25/2025
Date Signed: 04/25/2025 09:52:33 AM

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
10/20/2021 and conducted by Evaluator Raquel Hernandez
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20211020150235
FACILITY NAME:VALENCIA TERRACEFACILITY NUMBER:
336424105
ADMINISTRATOR:DYAN SUMMERELLFACILITY TYPE:
740
ADDRESS:2300 SOUTH MAIN STREETTELEPHONE:
(951) 273-1300
CITY:CORONASTATE: CAZIP CODE:
92882
CAPACITY:84CENSUS: 66DATE:
04/25/2025
UNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Administrator Edgar Gallardo TIME COMPLETED:
10:00 AM
ALLEGATION(S):
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Resident sustained unexplained injuries while in care
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Raquel Hernandez conducted an unannounced visit to deliver findings on the allegation listed above. LPA met with Administrator Edgar Gallardo and explained the purpose of the visit. The investigation consisted of staff interviews, resident interviews and document review.

For the allegation, Resident sustained unexplained injuries.

Investigation was conducted by Department staff which consisted of seven (7) staff interviews five (5) resident interviews and document review. Evidence revealed that resident had multiple falls while living at the facility and on two (2) occasion R1 was handled roughly by staff resulting in multiple injuries.
Staff interviews indicate that R1’s health rapidly declined and had multiple falls. Staff indicated that R1 would be found on the ground or hanging off the bed almost every day.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Raquel Hernandez
LICENSING EVALUATOR SIGNATURE:

DATE: 04/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2025
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 18-AS-20211020150235
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: VALENCIA TERRACE
FACILITY NUMBER: 336424105
VISIT DATE: 04/25/2025
NARRATIVE
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In addition, on 10/18/21 R1’s daughter and home health nurse observed staff handling R1 rough during a lift and transfer. On 10/19/21 video footage captures a staff improperly lifting R1 causing redness to R1’s arm.

Medical records show that R1 was diagnosed with Bilateral high riding humeral heads, suggestive of chronic rotator cuff tears and compression deformities of L3 and L4 vertebral bodies. Nursing notes also indicate R1 was observed to have several bruises to left arm and shoulder.

Based on the evidence gathered during the investigation, the allegation listed above is 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.

An exit interview was conducted and the forms LIC9099 and LIC9099D were discussed and left with Administrator Edgar Gallardo along with a copy of the appeal rights.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Raquel Hernandez
LICENSING EVALUATOR SIGNATURE:

DATE: 04/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 18-AS-20211020150235
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: VALENCIA TERRACE
FACILITY NUMBER: 336424105
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/25/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/28/2025
Section Cited
CCR
87468.1(3)
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87468.1 Personal Rights of Residents in all Facilities (3) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.

This requirement is not met as evidenced by:
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Licensee stated to submit photo documentation of all staff signing that they have read section 87468 Personal Rights of Residents in All Facilities by LPA Hernandez by Plan of Correction (POC) due date.
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Based on evidence and video footage, Licensee did not comply with the section cited above evidenced by Staff #2 (S2) improperly lifting Resident #1 (R1) and sustained bruising from using gait belt which poses an immediate health, safety, and personal rights risk 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: 04/25/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3