361881019-3-11-2022-18-AS-EMAN-CCXUDL-20220328152945

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 361881019
Report Date: 03/11/2022
Date Signed: 03/11/2022 12:58:58 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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
09/13/2021 and conducted by Evaluator Melody Brown

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20210913125516

FACILITY NAME:	WILDWOOD CANYON VILLA		FACILITY NUMBER:	361881019
ADMINISTRATOR:	OSORIO, JULIUS		FACILITY TYPE:	740
ADDRESS:	33951 COLORADO ST		TELEPHONE:	(909) 446-0405
CITY:	YUCAIPA	STATE: CA	ZIP CODE:	92399
CAPACITY:	130	CENSUS: 66	DATE:	03/11/2022
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Business Services Director Priscilla Mancilla		TIME COMPLETED:	01:15 PM

ALLEGATION(S):

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Resident had multiple falls while in care.
Resident sustained injuries while in care.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Melody Brown conducted an unannounced visit to the facility 03/11/2022 at 09:30 AM to deliver the finding of the above allegations. LPA Brown met with Business Services Director Priscilla Mancilla .

The investigation was conducted by the Department staff. The investigation consisted of file review and interviews with relevant parties. The first allegation indicated that resident had multiple falls while in care. Evidences shows that R1 sustained multiple falls while living at the facility. However, evidences also shows that the facility documented the falls, ensured that R1 was medically assessed, transported R1 to the hospital and notified R1's Power of Attorney (POA) after each fall. Also, 24- hour supervision and also placed R1 on hospice care. There is clear evidence that R1 sustained multiple unwitnessed falls while a resident of the facility, however the evidence also demonstrates that the facility acted appropriately by providing increased supervision and initiating measures in attempts to mitigate future falls. Therefore, based on ***Continuation on LIC9099C***

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 248-0337
LICENSING EVALUATOR NAME: Melody Brown	TELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:	DATE: 03/11/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 18-AS-20210913125516

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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

FACILITY NAME: WILDWOOD CANYON VILLA	FACILITY NUMBER: 361881019
	VISIT DATE: 03/11/2022

NARRATIVE

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the evidence obtained during the Department's investigation, the allegation of resident had multiple falls while in care is unsubstantiated at this time.

The second allegation alleges that R1 sustained injuries while in care. During the course of the investigation, Department staff obtained evidence that indicates R1 had multiple falls while at the facility. Medical records show that R1 sustained bruises to his head and face. However, there is no evidence that shows R1's injuries contributed to resident's death. Hospice Records including the Death certificate indicate that R1 expired due to natural causes and there is nothing documented as a contributing factor to R1's death. There is insufficient evidence to show that R1 sustained serious injuries as a result of neglect/lack of supervision.

Although the allegations resident had multiple falls while in care (allegation #1) and resident sustained injuries while in care (allegation #2) may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegations are unsubstantiated at this time.

No deficiencies were cited. An exit interview was conducted where this report (LIC9099) was discussed and provided to Business Services Director Priscilla Mancilla .

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 248-0337
LICENSING EVALUATOR NAME: Melody Brown	TELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:	DATE: 03/11/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2022

LIC9099 (FAS) - (06/04)

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