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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 366413072
Report Date: 10/25/2024
Date Signed: 10/25/2024 02:38:43 PM

Unsubstantiated


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
08/06/2024 and conducted by Evaluator Magda Malcore
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20240806142453
FACILITY NAME:VILLAS AT SAN BERNARDINOFACILITY NUMBER:
366413072
ADMINISTRATOR:CARLTON, KENYAFACILITY TYPE:
740
ADDRESS:2985 NORTH G STREETTELEPHONE:
(909) 883-7703
CITY:SAN BERNARDINOSTATE: CAZIP CODE:
92405
CAPACITY:0CENSUS: 0DATE:
10/25/2024
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Kenya CarltonTIME COMPLETED:
02:45 PM
ALLEGATION(S):
1
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5
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9
Staff did not ensure resident had wound care
Staff are not ensuring resident hygiene needs are being met
INVESTIGATION FINDINGS:
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5
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9
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13
Licensing Program Analyst (LPA) Magda Malcore conducted an unannounced visit to the facility to conclude the investigation on the above allegations. LPA met with Kenya Carlton, Executive Director, and discussed the purpose of the visit. The investigation consisted of LPA record review, interviews with staff and residents.

Regarding the allegation, staff did not ensure resident had wound care, it was alleged that resident #1 (R1) had untreated foot wounds with maggots. LPA record review reveals that R1 was receiving wound care through Home Health care. Five (5) staff interviewed deny not ensuring residents had wound care. R1 was not interviewed as they no longer reside at the facility. Five (5) residents interviewed stated they had no wounds. In addition, there is no medical documentation of maggots on R1.

Regarding the allegation, staff are not ensuring resident hygiene needs are being met, five (5) staff interviewed deny not ensuring resident hygiene needs are being met. Five (5) residents interviewed stated that their hygiene needs are being met.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Magda Malcore
LICENSING EVALUATOR SIGNATURE:

DATE: 10/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2024
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
Control Number 56-AS-20240806142453
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: VILLAS AT SAN BERNARDINO
FACILITY NUMBER: 366413072
VISIT DATE: 10/25/2024
NARRATIVE
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Based on record review and interviews during this investigation, the mentioned in this report above are Unsubstantiated; meaning that although the allegation(s) may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur.

An exit interview was conducted with where this report was discussed. A copy of this report was provided with appeal rights to the Executive Director at the conclusion of the visit.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Magda Malcore
LICENSING EVALUATOR SIGNATURE:

DATE: 10/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2