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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366413072
Report Date: 05/02/2022
Date Signed: 05/02/2022 12:34:34 PM


Document Has Been Signed on 05/02/2022 12:34 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507



FACILITY NAME:VILLAS AT SAN BERNARDINOFACILITY NUMBER:
366413072
ADMINISTRATOR:SHANNON JOHNSONFACILITY TYPE:
740
ADDRESS:2985 NORTH G STREETTELEPHONE:
(909) 883-7703
CITY:SAN BERNARDINOSTATE: CAZIP CODE:
92405
CAPACITY:97CENSUS: 79DATE:
05/02/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:48 AM
MET WITH:Tomi MoralesTIME COMPLETED:
12:36 PM
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Licensing Program Analyst (LPA) Anna Bueno conducted a case management visit to the facility to discuss the SOC 341 that the facility submitted to the Department.

LPA Bueno inquired as to what the outcome of the investigation was with Executive Director Tomi Morales. Morales stated that on 4/17/22, staff noticed that R1 had a skin tear and when Resident 1 (R1) and the family member were asked separately, their story was the same. Morales stated that a week after this incident, staff overheard R1 tell another resident that the family member makes R1 engage in sex even when R1 does not want to. Morales stated that when staff spoke with R1, R1 denies being sexually abused however stated their family member hurts them. Morales explained there was no physical evidence to determine if in fact Resident 1 (R1) is being abused by their family member. Morales stated that when staff spoke with the family member, they stated that when R1 is upset, anxious, and cries, the family member will grab R1 under the shoulders, shake them, and yell their name. However the family member stated they have not done this recently. The facility has been conducting body checks on R1 before and after visits with the family member. Morales stated that they have been notified that the Ombudsman will be meeting with the family member to investigate the matter..

No deficiencies were cited during today's visit. An exit interview was conducted where this report was discussed and a copy was provided to Ms. Morales at the conclusion of the visit.
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Anna BuenoTELEPHONE: 951-204-4307
LICENSING EVALUATOR SIGNATURE:
DATE: 05/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/02/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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