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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 366405765
Report Date: 07/10/2025
Date Signed: 07/10/2025 01:01:10 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
06/30/2025 and conducted by Evaluator Becky Mann
COMPLAINT CONTROL NUMBER: 56-AS-20250630151815
FACILITY NAME:CASA COLINA CENTERS FOR REHABILITATION/PADUA VILLAFACILITY NUMBER:
366405765
ADMINISTRATOR:STEPHANIE E. KAPLANFACILITY TYPE:
735
ADDRESS:22200 HIGHWAY 18TELEPHONE:
(760) 247-7711
CITY:APPLE VALLEYSTATE: CAZIP CODE:
92307
CAPACITY:54CENSUS: DATE:
07/10/2025
UNANNOUNCEDTIME BEGAN:
11:50 AM
MET WITH:J. Rosa Tucker, Program DirectorTIME COMPLETED:
01:10 PM
ALLEGATION(S):
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Staff mismanage residents' medication
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Becky Mann conducted an unannounced visit to the facility to initiate a complaint investigation. LPA met with J. Rosa Tucker, Program Director and explained the purpose of the visit. The investigation consisted of LPA pertinent record reviews, observations and interviews with staff and residents.

The allegation that staff mismanage residents' medication. LPA interviewed Staff #1 (S1), they provided the wrong medication to Resident #1 (R1). S1 packed Resident #2 (R2) medications for R1 during their outing. The facility provided a Special Incident Report (SIR) to Community Care Licensing (CCL) about the medication error on June 24, 2025. The incident happened on June 18, 2025.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Becky Mann
LICENSING EVALUATOR SIGNATURE:

DATE: 07/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/10/2025
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 4
Control Number 56-AS-20250630151815
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: CASA COLINA CENTERS FOR REHABILITATION/PADUA VILLA
FACILITY NUMBER: 366405765
VISIT DATE: 07/10/2025
NARRATIVE
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Based on LPA observations, interviews and records review, the above allegation is Substantiated. A determination that the complaint is substantiated means that the allegation is/are valid because the preponderance of the evidence standard has been met.

An exit interview was conducted where this report, appeal rights and LIC9099D page was reviewed and provided to J. Rosa Tucker, Program Director.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Becky Mann
LICENSING EVALUATOR SIGNATURE:

DATE: 07/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/10/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 56-AS-20250630151815
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: CASA COLINA CENTERS FOR REHABILITATION/PADUA VILLA
FACILITY NUMBER: 366405765
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/10/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/11/2025
Section Cited
HSC
80075(b)(5)(B)
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80075 Health Related Services(b)Clients assisted as needed with self-administration prescription and nonprescription meds. (5)...facility staff... assist client with self-administration...(B).. medication given according to physician's directions. Requirement has not been met:
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Program Director will submit a Statement of Understanding and training with staff signatures to LPA by Plan of Correction (POC) due date
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Based on LPA observations, interviews and record reviews. Staff #1 (S1) provided the wrong medications to Resident #1 (R1). S1 packed Resident #2 (R2) medications for R1 during their outing. Which poses an immediate health and safety concern for residents 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: Nedra Brown
LICENSING EVALUATOR NAME: Becky Mann
LICENSING EVALUATOR SIGNATURE:

DATE: 07/10/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/10/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 4
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
06/30/2025 and conducted by Evaluator Becky Mann
COMPLAINT CONTROL NUMBER: 56-AS-20250630151815

FACILITY NAME:CASA COLINA CENTERS FOR REHABILITATION/PADUA VILLAFACILITY NUMBER:
366405765
ADMINISTRATOR:STEPHANIE E. KAPLANFACILITY TYPE:
735
ADDRESS:22200 HIGHWAY 18TELEPHONE:
(760) 247-7711
CITY:APPLE VALLEYSTATE: CAZIP CODE:
92307
CAPACITY:54CENSUS: DATE:
07/10/2025
UNANNOUNCEDTIME BEGAN:
11:50 AM
MET WITH:J. Rosa Tucker, Program DirectorTIME COMPLETED:
01:10 PM
ALLEGATION(S):
1
2
3
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5
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7
8
9
Staff are not permitting resident to visit their family
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Becky Mann conducted an unannounced visit to the facility to initiate a complaint investigation. LPA met with J. Rosa Tucker, Program Director and explained the purpose of the visit. The investigation consisted of LPA pertinent record reviews, observations and interviews with staff and residents.
The allegation that staff are not permitting resident to visit their family. Four (4) staff interviewed stated that they do allow residents to visit their family. Five (5) residents interviewed stated that staff does allow them to visit their family.

Based on evidence obtained during this investigation, the allegations above are 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 was discussed and a copy of this report was provided to J. Rosa Tucker at the conclusion of the visit.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Becky Mann
LICENSING EVALUATOR SIGNATURE:

DATE: 07/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/10/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 4