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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 366426335
Report Date: 02/17/2021
Date Signed: 02/17/2021 02:21:48 PM



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
RIVERSIDE, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/11/2021 and conducted by Evaluator Christine Le
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20210211133609
FACILITY NAME:KNOLLS WEST ASSISTED LIVINGFACILITY NUMBER:
366426335
ADMINISTRATOR:TERRONSAY WHALEYFACILITY TYPE:
740
ADDRESS:16890 GREEN TREE BLVD.TELEPHONE:
(760) 245-0107
CITY:VICTORVILLESTATE: CAZIP CODE:
92395
CAPACITY:64CENSUS: 39DATE:
02/17/2021
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Erwina AmoreTIME COMPLETED:
11:00 AM
ALLEGATION(S):
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Staff are not treating a resident with dignity
Facility call button is inoperable
Staff are not making appropriate medical care arrangements for a resident in care
Staff not assisting resident with pain medication
Staff did not help resident with incontinence needs
Staff did not report resident's incidents to authorized representative
Facility is not answering the phone promptly
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Christine Le contacted the facility via telephone to commence a complaint investigation due to COVID-19. LPA identified herself and discussed the purpose of the call and the elements of the allegations with assistant administrator Erwina Amore.

The allegations are in regards to Resident 1 (R1)'s care. LPA was informed by the assistant administrator and administrator that Resident 1 (R1) was never admitted to the facility and resides at the skilled nursing facility Knolls West Post Acute located on the same property. LPA reviewed a copy of the resident roster and observed that R1 was not listed as a resident. LPA also spoke with R1's responsible party who confirmed that R1 was a patient at the skilled nursing facility and did not reside at the assisted living facility. LPA advised that the complaint will be unfounded as skilled nursing facilities are not within CCLD's jurisdiction.

This agency has investigated the complaint allegation. We have found that the complaint was unfounded
meaning that the allegation was false, could not have happened and/or is without a reasonable basis.
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Christine LeTELEPHONE: (951) 897-2618
LICENSING EVALUATOR SIGNATURE:

DATE: 02/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/17/2021
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 18-AS-20210211133609
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
RIVERSIDE, CA 92507
FACILITY NAME: KNOLLS WEST ASSISTED LIVING
FACILITY NUMBER: 366426335
VISIT DATE: 02/17/2021
NARRATIVE
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No deficiencies were cited during this visit. An exit interview was conducted with the assistant administrator via telephone and a copy of this report was provided to the assistant administrator via email. Report with facility representative signature was obtained.
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Christine LeTELEPHONE: (951) 897-2618
LICENSING EVALUATOR SIGNATURE:

DATE: 02/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/17/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 2