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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 365530213
Report Date: 12/31/2024
Date Signed: 12/31/2024 12:05:25 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
10/03/2024 and conducted by Evaluator Renese Howell-Small
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20241003160211
FACILITY NAME:VILLAS AT SAN BERNARDINOFACILITY NUMBER:
365530213
ADMINISTRATOR:CARLTON, KENYAFACILITY TYPE:
740
ADDRESS:2985 N G STREETTELEPHONE:
(323) 475-1800
CITY:SAN BERNARDINOSTATE: CAZIP CODE:
92405
CAPACITY:144CENSUS: 91DATE:
12/31/2024
UNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Executive Director, Kenya CarltonTIME COMPLETED:
12:05 PM
ALLEGATION(S):
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Staff mismanaged resident medication
INVESTIGATION FINDINGS:
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On 12/31/2024 at 9:15AM Licensing Program Analyst (LPA) Renese Howell-Small conducted an unannounced visit to the facility and met with Executive Director, Kenya Carlton for the purpose of delivering findings for the above allegation. LPA was greeted by staff, introduced self and stated the purpose of the visit.

Regarding the allegation of staff mismanaged resident medication and based on an in-person interview with Executive Director, Kenya Carlton LPA Small confirmed that Resident #1 (R1) went to the hospital on 09/28/2024 and was released on 09/29/2024. Once R1 was released at 4:00PM on 09/29/2024, R1's discharge papers were faxed the same day but did not include a copy of the prescription. As a result R1 did not receive and was not given the prescribed medication until 10/01/2024. LPA interviewed staff, audited R1's MAR for the months of September and October, reviewed the Unsual Incident/Injury Report (SIR) and the discharge notes from the physician.

Based on the evidence gathered during the investigation and in accordance with Title 22 regulation 87465 (a) (2), the above allegation is SUBSTANTIATED.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Renese Howell-Small
LICENSING EVALUATOR SIGNATURE:

DATE: 12/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/31/2024
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-20241003160211
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: VILLAS AT SAN BERNARDINO
FACILITY NUMBER: 365530213
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/31/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/02/2025
Section Cited
CCR
87465(a)(2)
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 87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility... (2) Once ordered... given according to physician's directions.
This standard was not met as evidenced by:
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Licensee/Administrator has agreed to conduct Medication Training on CCR 87465(a)(2) to all staffs dispensing medications to residents and submit proof to LPA Howell-Small on Plan of Correction (POC) due date.
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Based on interview, obervation and record review theLicensee/Administrator did not comply with the section cited above by not ensuring that medication was given to resident #1 (R1) in care after (R1) returned from the hospital, which poses an immediate health, safety, or personal rights risk to persons 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: Karen Clemons
LICENSING EVALUATOR NAME: Renese Howell-Small
LICENSING EVALUATOR SIGNATURE:

DATE: 12/31/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/31/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 56-AS-20241003160211
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: VILLAS AT SAN BERNARDINO
FACILITY NUMBER: 365530213
VISIT DATE: 12/31/2024
NARRATIVE
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SUBSTANTIATED is defined as The “preponderance of the evidence” standard has been met.

A deficiency was cited.

An exit interview was discussed and a copy of this report, LIC9099, LIC9099C, LIC9099D and Appeal Rights was left with Executive Director, Kenya Carlton.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Renese Howell-Small
LICENSING EVALUATOR SIGNATURE:

DATE: 12/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/31/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3