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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 366413072
Report Date: 02/22/2023
Date Signed: 02/22/2023 12:00:36 PM

Substantiated


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
02/13/2023 and conducted by Evaluator Anna Bueno
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20230213140549
FACILITY NAME:VILLAS AT SAN BERNARDINOFACILITY NUMBER:
366413072
ADMINISTRATOR:YVETTE NAVARROFACILITY TYPE:
740
ADDRESS:2985 NORTH G STREETTELEPHONE:
(909) 883-7703
CITY:SAN BERNARDINOSTATE: CAZIP CODE:
92405
CAPACITY:97CENSUS: 81DATE:
02/22/2023
UNANNOUNCEDTIME BEGAN:
09:18 AM
MET WITH:Kenya Carlton, AdministratorTIME COMPLETED:
12:03 PM
ALLEGATION(S):
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Facility refusing resident from having visitors.
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPA) Anna Bueno conducted an unannounced visit to the facility to initiate the complaint investigation and deliver findings on the above allegation. LPA met with administrator Kenya Carlton who was informed of the purpose of today’s visit. The investigation consisted of interviews with relevant parties, and review relevant records.

It is alleged that the Facility is refusing Resident (R1) from having visitors. Resident interview confirm that they have specific visitors they would like to see. Staff interview confirmed that specific R1 visitors have been refused by the facility at least one time, since receiving instructions from POA. Interview with Power of Attorney (POA) confirmed POA gave instructions to the facility not to allow specific visitors from seeing R1. Witness interview confirmed that they notified specific visitors not to visit R1 until R1 has settled in the community. LPA reviewed communication from POA regarding the visitor restriction and R1 admissions agreement, including resident personal rights, signed by POA. Based on the above information, this allegation is substantiated.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Anna BuenoTELEPHONE: 951-204-4307
LICENSING EVALUATOR SIGNATURE:

DATE: 02/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/22/2023
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-20230213140549
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 BERNARDINO
FACILITY NUMBER: 366413072
VISIT DATE: 02/22/2023
NARRATIVE
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A finding that the complaint is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met. This poses a potential risk health and safety risk to residents in care.

Refer to LIC809-D for deficiency cited. An exit interview was conducted where this report, LIC809-D, and appeal rights were discussed with and provided to Administrator Carlton.
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Anna BuenoTELEPHONE: 951-204-4307
LICENSING EVALUATOR SIGNATURE:

DATE: 02/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/22/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 56-AS-20230213140549
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 BERNARDINO
FACILITY NUMBER: 366413072
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/22/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/22/2023
Section Cited
CCR
87468.1(a)(11)
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Personal Rights of Residents in All Facilities
(11) To have their visitors, including ombudspersons and advocacy representatives, permitted to visit privately during reasonable hours and without prior notice, provided that the rights of other residents are not infringed upon.
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Licensee shall allow all visitors. Licensee has updated visitation guidelines as of today.
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This requirement was not met as evidenced by:

Interviews confirmed that specific visitors are not allowed to see R1. This poses a potential health and safety risk to 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.
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Anna BuenoTELEPHONE: 951-204-4307
LICENSING EVALUATOR SIGNATURE:

DATE: 02/22/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/22/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3