<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 361880786
Report Date: 03/26/2026
Date Signed: 03/26/2026 04:06:57 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
06/10/2024 and conducted by Evaluator Paola Guerrero
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20240610140619
FACILITY NAME:SUMMERFIELD OF REDLANDSFACILITY NUMBER:
361880786
ADMINISTRATOR:HEDI CHARETTEFACILITY TYPE:
740
ADDRESS:1319 BROOKSIDE AVENUETELEPHONE:
(909) 793-9500
CITY:REDLANDSSTATE: CAZIP CODE:
92373
CAPACITY:75CENSUS: 38DATE:
03/26/2026
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Rachelle LlamasTIME COMPLETED:
04:10 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not administer resident’s medication as prescribed
Staff did not meet resident’s medical needs
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Paola Guerrero arrived at the facility to deliver investigative findings. LPA met with Facility Administrator Rachelle Llamas and explained the purpose of the visit regarding the allegation stated above.

First allegation: Staff did not administer resident’s medication as prescribed. Regarding the first allegation LPA conducted a record review pertaining to Resident #1 during the review of records LPA discovered than on 6/9/2024, Resident#1 was transported to a local hospital by Emergency Medical Services (EMS) due to back pain from a previous fall Resident #1 had sustained on 1/21/2024. In addition, records also showed that EMS reported that staff did not administer Norco dosage that morning to Resident #1 which caused residents pain to increase. Furthermore, records also show that upon EMS arrival Resident #1 was administered their prescribed Norco. Records show that Resident #1 was admitted on 6/9/2024 and discharged on same day.

Second allegation: Staff did not meet resident’s medical needs.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Paola Guerrero
LICENSING EVALUATOR SIGNATURE:

DATE: 03/26/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/26/2026
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 5
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
06/10/2024 and conducted by Evaluator Paola Guerrero
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20240610140619

FACILITY NAME:SUMMERFIELD OF REDLANDSFACILITY NUMBER:
361880786
ADMINISTRATOR:HEDI CHARETTEFACILITY TYPE:
740
ADDRESS:1319 BROOKSIDE AVENUETELEPHONE:
(909) 793-9500
CITY:REDLANDSSTATE:CAZIP CODE:
92373
CAPACITY:75CENSUS: 38DATE:
03/26/2026
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Rachelle LlamasTIME COMPLETED:
04:10 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not meet resident’s diapering needs
Night shift staff are unavailable to provide assistance
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Paola Guerrero arrived at the facility to deliver investigative findings. LPA met with Facility Administrator Rachelle Llamas and explained the purpose of the visit regarding the allegation stated above.

First allegation: Staff did not meet resident’s diapering needs. Regarding the allegation stated above, the department conducted interviews with Staff #1, Staff #2, Staff #3, and Staff #4 regarding the allegation stated above and Staff #1-4 indicated that diapering needs and care services were provided to Resident #1. In addition, Staff #1-4 denied the allegation “Staff did not meet resident’s diapering needs”. The department conducted interviews with R#2, R#3, R#4 and R#5, regarding the allegation stated above and all resident’s reported staff were meeting their diapering needs. In addition, R#2-5 reported not having concerns pertaining to their care and indicated that staff are meeting their care needs.

Second allegation: Night shift staff are unavailable to provide assistance.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Paola Guerrero
LICENSING EVALUATOR SIGNATURE:

DATE: 03/26/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/26/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 56-AS-20240610140619
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: SUMMERFIELD OF REDLANDS
FACILITY NUMBER: 361880786
VISIT DATE: 03/26/2026
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
 Regarding the allegation stated above, LPA conducted an interview with Staff #5 regarding the alleged allegation stated above Staff #5 informed LPA that the facility is currently staffed and provided LPA with facility’s most recent personnel roster. During the review of staff roster LPA observed that the facility has four cottages and during night shift each cottage is split by three (3), caregivers who work the night shift and provide care to a total of 38 residents. LPA conducted an interview with Resident #6, Resident #7, and Resident #8, regarding the allegation stated above and R#6-8 informed LPA that the facility is currently providing enough care and night supervision for all residents in care. In addition, R#6-8 reported to LPA that they feel safe and have no concerns to report pertaining to staff. Based on corroborating evidence LPA has determined that the above allegation is Unsubstantiated, meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur.

An exit interview was conducted where this report (LIC 9099) was discussed, and a copy was provided to Facility Administrator Rachelle Llamas.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Paola Guerrero
LICENSING EVALUATOR SIGNATURE:

DATE: 03/26/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/26/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 56-AS-20240610140619
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: SUMMERFIELD OF REDLANDS
FACILITY NUMBER: 361880786
VISIT DATE: 03/26/2026
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
Regarding the allegation stated above, LPA conducted a record review pertaining to Resident #1 upon the review of records, LPA discovered that Resident #1 had sustained a total of four unwitnessed falls which occurred on (01/08/2024, 01/21/2024, 03/09/2024, and 03/19/2024), and on 06/09/2024 Resident #1 was transported to local hospital and was seen for back pain due to the cause of staff not administering Resident#1 medication which resulted on Resident #1 to have increase backpain. Due to staff not being able to provide Resident #1 with the required services based on the resident care needs, the allegation is substantiated. A finding that the complaint is Substantiated means that the findings are valid because the preponderance of the evidence standard has been met. Title 22 regulations Incidental Medical and Dental Care 87465 (a)(2) & (4), from division 6, chapter, article 6, is, cited on the attached LIC 9099 D.

An exit interview was conducted where this report, appeal rights, and LIC9099-D was discussed, and a copy of the report was provided to Facility Administrator Rachelle Llamas the conclusion of the visit.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Paola Guerrero
LICENSING EVALUATOR SIGNATURE:

DATE: 03/26/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/26/2026
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 56-AS-20240610140619
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: SUMMERFIELD OF REDLANDS
FACILITY NUMBER: 361880786
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/26/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/10/2026
Section Cited
CCR
87465(a)(4)
1
2
3
4
5
6
7
Incidental Medical and Dental Care 87465 (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following:
(4) The licensee shall assist residents with self-administered medications as needed.

This requirement is not met as evidence by:
1
2
3
4
5
6
7
The Licensee has agreed to read over the "Incidental Medical and Dental Care" regulation and provide training pertaining to the administration of medication to all Med-Techs and staff who administer medication. The Licensee will email LPA with the copy and sign-in sheet of the training by POC 4/10/2026.
8
9
10
11
12
13
14
Based on record review, interviews, the licensee did not ensure to follow Incidental Medical and Dental Care, by not administering R#1 medication based on doctors orders, which poses an immediate Health, Safety, or Personal Rights risk to residents in care
8
9
10
11
12
13
14
Type B
04/10/2026
Section Cited
CCR
87465(a)(2)
1
2
3
4
5
6
7
Incidental Medical and Dental Care 87465 (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following:
(2) The licensee shall provide assistance in meeting necessary medical and dental needs. This includes transportation which may be limited to the nearest available medical or dental facility which will meet the resident's need. In providing transportation the licensee shall do so directly or make arrangements for this service.

This requirement is not met as evidence by:
1
2
3
4
5
6
7
The Licensee has agreed to read over the "Incidental Medical and Dental Care" regulation and provide training pertaining to meeting the needs of each resident according to their medical needs. The Licensee will email LPA with the copy and sign-in sheet of the training by POC 4/10/2026.
8
9
10
11
12
13
14
Based on record review, interviews, the licensee did not ensure to follow Incidental Medical and Dental Care, by not providing R#1 with the proper medical services according to R#1 medical needs, which poses an immediate Health, Safety, or Personal Rights risk to residents in care
8
9
10
11
12
13
14
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Efren Malagon
LICENSING EVALUATOR NAME: Paola Guerrero
LICENSING EVALUATOR SIGNATURE:

DATE: 03/26/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/26/2026
LIC9099 (FAS) - (06/04)
Page: 5 of 5