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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 366413072
Report Date: 05/02/2022
Date Signed: 05/02/2022 11:51:57 AM

Unfounded


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/26/2022 and conducted by Evaluator Anna Bueno
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20220426151709
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
UNANNOUNCEDTIME BEGAN:
08:52 AM
MET WITH:Tomi MoralesTIME COMPLETED:
11:48 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Resident's medical records are not being provided to their representative as required
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Anna Bueno conducted an unannounced visit to this facility for the purpose of initiating the investigation of and delivering findings for the above allegations. LPA Bueno met with Tomi Morales, executive director and administrator and was advised the purpose of visit. The investigation consisted of various interviews and observation of documentation relative to the allegations. Below is a summary of the finding of the investigation:
The allegation is Resident's medical records are not being provided to their representative as required. During the investigation, it was discovered that any other form of record copies was not accepted unless they were electronic. Access to an electronic record hosting service was received by the facility and the facility submitted the requested records on this hosting service the same day.
Based on the available information, we have found the complaint allegation is UNFOUNDED. A finding of unfounded means that the allegations were false, could not have happened and/or is without a reasonable basis. An exit interview was conducted where this report (LIC 9099) was discussed and a copy was provided to Ms. Morales at the conclusion of the visit.
Unfounded
Estimated Days of Completion:
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.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/26/2022 and conducted by Evaluator Anna Bueno
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20220426151709

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: DATE:
05/02/2022
UNANNOUNCEDTIME BEGAN:
08:52 AM
MET WITH:Tomi MoralesTIME COMPLETED:
11:48 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Resident's Representative's requests for communication are not being responded to in a timely manner.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Anna Bueno conducted an unannounced visit to this facility for the purpose of initiating the investigation of and delivering findings for the above allegations. LPA Bueno met with Tomi Morales, executive director and administrator and was advised the purpose of visit. The investigation consisted of various interviews and observation of documentation relative to the allegations. Below is a summary of the finding of the investigation:
The allegation is Resident's Representative's requests for communication are not being responded to in a timely manner. Interviews revealed that both parties were consistently in touch. Facility staff were unable to communicate with resident representative when they were off work.
Based on the available information, we have found the complaint allegation is UNSUBSTANTIATED. A finding of 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 (LIC 9099) was discussed and a copy was provided to Ms. Morales at the conclusion of the visit.
Unsubstantiated
Estimated Days of Completion:
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.
LIC9099 (FAS) - (06/04)
Page: 2 of 2