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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 366405765
Report Date: 09/21/2022
Date Signed: 09/21/2022 01:45:07 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
03/16/2021 and conducted by Evaluator Natalie Ibarra
COMPLAINT CONTROL NUMBER: 18-AS-20210316092711
FACILITY NAME:CASA COLINA CENTERS FOR REHABILITATION/PADUA VILLAFACILITY NUMBER:
366405765
ADMINISTRATOR:RODNEY PEEKFACILITY TYPE:
735
ADDRESS:22200 HIGHWAY 18TELEPHONE:
(760) 247-7711
CITY:APPLE VALLEYSTATE: CAZIP CODE:
92307
CAPACITY:54CENSUS: 33DATE:
09/21/2022
UNANNOUNCEDTIME BEGAN:
01:07 PM
MET WITH:Rodney PeekTIME COMPLETED:
02:00 PM
ALLEGATION(S):
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9
Staff caused injury to resident.
INVESTIGATION FINDINGS:
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13
Licensing Program Analyst (LPA) Natalie Gayoso Ibarra made an unannounced visit to the facility to deliver findings. LPA met with administrator Rodney Peek and explained the purpose of today’s visit. The investigation consisted of interviews with pertinent parties.

The first allegation indicates staff caused injury to resident. Interviews with Staff #5 (S5) and Staff #6 (S6) stated that Client #1’s (C1) face had scratches after an altercation with Staff #2 (S2). S5 also stated they witnessed S2 slap C1 in the face. Staff #4 (S4) noticed redness across C1’s left cheek. Interview with C1 stated that S2 slapped them in the face and dragged their nails down causing scratches on C1’s face.

Based on interviews which were conducted, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22 Division 6 & Chapter 6, are being cited on the attached LIC 9099D
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Natalie Ibarra
LICENSING EVALUATOR SIGNATURE:

DATE: 09/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2022
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 4
Control Number 18-AS-20210316092711
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: CASA COLINA CENTERS FOR REHABILITATION/PADUA VILLA
FACILITY NUMBER: 366405765
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/21/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/21/2022
Section Cited
CCR
80072(a)(1)
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7
Personal Rights(a)(1): (a)...each client shall have personal rights which include...the following:(1)To be accorded dignity in his/her personal relationships with staff and other persons
This requirement was not met as evidenced by:
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Employee has been terminated as of 3/8/2021 and training has been provided to all staff regarding staff conduct with clients. No further action required
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Based on interviews S2 slapped and scratched C1’s face during an altercation. This poses a potential safety risk to clients in care.
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7
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: Natalie Ibarra
LICENSING EVALUATOR SIGNATURE:

DATE: 09/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 4
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
03/16/2021 and conducted by Evaluator Natalie Ibarra
COMPLAINT CONTROL NUMBER: 18-AS-20210316092711

FACILITY NAME:CASA COLINA CENTERS FOR REHABILITATION/PADUA VILLAFACILITY NUMBER:
366405765
ADMINISTRATOR:RODNEY PEEKFACILITY TYPE:
735
ADDRESS:22200 HIGHWAY 18TELEPHONE:
(760) 247-7711
CITY:APPLE VALLEYSTATE: CAZIP CODE:
92307
CAPACITY:54CENSUS: DATE:
09/21/2022
UNANNOUNCEDTIME BEGAN:
01:07 PM
MET WITH:Rodney PeekTIME COMPLETED:
02:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility staff used foul language toward residents
Resident's room poses as a safety hazard to all residents.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Natalie Gayoso Ibarra made an unannounced visit to the facility to deliver findings. LPA met with administrator Rodney Peek and explained the purpose of today’s visit. The investigation consisted of interviews with pertinent parties.

The first allegation indicates facility staff used foul language toward residents. Interview with Client #1 (C1) stated Staff #2 (S2) did not use foul language towards them. Interviews with Staff #4 (S4) and Staff #5 (S5) stated they did not witness S2 use any foul language towards C1.

The second allegation indicates resident's room poses as a safety hazard to all residents. Interviews with S2, S3, and S4 indicated that Client #2 (C2) room is not in a hazardous state and that C2 keeps room clean. Interview with C2 stated they constantly clean their room and staff will ask if assistance is needed. LPA observed C2's room to be clean, did not contain odors, and was not fill of trash bags. LPA did not observe room to be a safety hazard.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Natalie Ibarra
LICENSING EVALUATOR SIGNATURE:

DATE: 09/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 18-AS-20210316092711
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: CASA COLINA CENTERS FOR REHABILITATION/PADUA VILLA
FACILITY NUMBER: 366405765
VISIT DATE: 09/21/2022
NARRATIVE
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Based on the information obtained, the allegations are UNSUBSTANTIATED. A finding of UNSUBSTANTIATED means that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur.


An exit interview was conducted, and a copy of this report, LIC 9099D, and Appeal Rights were provided to the Administrator
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Natalie Ibarra
LICENSING EVALUATOR SIGNATURE:

DATE: 09/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 4