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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 366426335
Report Date: 04/13/2026
Date Signed: 05/04/2026 01:39:59 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO ASC, 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
04/03/2026 and conducted by Evaluator Eldin Serrano
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20260403115257
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: 55DATE:
04/13/2026
UNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Janeth Gonzalez, Assistant AdministratorTIME COMPLETED:
11:20 AM
ALLEGATION(S):
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Staff do not respond to residents' requests for assistance.
Staff are not following universal precautions to prevent the spread of infectious disease.
Staff do not treat residents with respect.
INVESTIGATION FINDINGS:
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***This is an amendment****

On 4/13/2026 at 9:20 AM, Licensing Program Analyst (LPA) Eldin Serrano made an unannounced visit to the facility to amend and deliver the findings of the above allegations. LPA Serrano met with Assistant Administrator Janeth Gonzalez to explain the purpose of the visit. The investigation consisted of file review, interviews with facility staff and residents as well as facility observation.

Allegation #1: Staff do not respond to residents' requests for assistance. – Based on interviews with staff and residents, all of them confirmed that staff respond to residents’ requests for assistance in a timely manner when they pull the call light button. The allegation cannot be substantiated.

*** Continuation in LIC9099C ***
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Eldin Serrano
LICENSING EVALUATOR SIGNATURE:

DATE: 04/13/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/13/2026
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 4
Control Number 56-AS-20260403115257
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: KNOLLS WEST ASSISTED LIVING
FACILITY NUMBER: 366426335
VISIT DATE: 04/13/2026
NARRATIVE
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Allegation #2: Staff are not following universal precautions to prevent the spread of infectious disease. - Based on interviews with residents and staff, all parties reported that universal precautions were consistently followed to prevent the spread of infectious diseases. Resident #1 (R1) was evaluated by an external provider, who determined that R1 had shingles after another resident had already been placed in the same room. Facility staff are not medical professionals and relied on external assessments. Both residents are under quarantine. The allegation cannot be substantiated.

Allegation #3: Staff do not treat residents with respect. – Interviews with staff and residents indicated that staff treat residents respectfully. When behavioral issues arise, staff use communication and redirection techniques to de-escalate the situation. There was no evidence that residents were placed in time-out for inappropriate behavior. Therefore, this allegation is unsubstantiated.

Information received during investigation LPA did not find evidence to corroborate the allegations.

Based on the evidence, the allegations mentioned above are UNSUBSTANTIATED. A finding that the complaint is UNSUBSTANTIATED means 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, therefore the allegation is unsubstantiated at this time.

An exit interview was conducted where this report, LIC9099 and LIC9099C were discussed and provided to Janeth Gonzalez.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Eldin Serrano
LICENSING EVALUATOR SIGNATURE:

DATE: 04/13/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/13/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO ASC, 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
04/03/2026 and conducted by Evaluator Eldin Serrano
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20260403115257

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: 55DATE:
04/13/2026
UNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Erwina Amore, Social WorkerTIME COMPLETED:
11:20 AM
ALLEGATION(S):
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Staff are mismanaging medications.
INVESTIGATION FINDINGS:
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On 4/13/2026, Licensing Program Analysts (LPA) Eldin Serrano visited the facility to investigate the above-mentioned allegation and deliver findings. LPA met with social worker Erwina Amore to discuss the purpose of the visit. The investigation consisted of interviewing relevant parties, file review and observation.

The allegation indicates that Staff are mismanaging medications. – Based on the LPA’s review of the Medication Administration Records (MAR), conducted with assistance from the assistant administrator, it was determined that MedTech staff did not administer medications in accordance with prescribed instructions. The dates documented on the MAR did not align with the corresponding medication bubble packs. Therefore, the allegation is substantiated.

Based on interviews and file review, the preponderance of evidence standard has been met, therefore, the allegation is substantiated under the California Code of Regulations (Title 22, Division 6 & Chapter 8).

An exit interview was conducted, where this report, LIC9099, LIC9099D along with appeal rights, were provided to Erwina Amore .

Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Eldin Serrano
LICENSING EVALUATOR SIGNATURE:

DATE: 04/13/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/13/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 56-AS-20260403115257
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: KNOLLS WEST ASSISTED LIVING
FACILITY NUMBER: 366426335
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/13/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/20/2026
Section Cited
CCR
87465(6)
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Title 22, Division 6 Chapter 8 Article 08 87465 Incidental Medical and Dental Care (6)When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility.
This requirement is not met as evidence by:
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The Licensee shall retrain staff on medication management training conducted by a medical professional. Training documentation shall include the name of the trainer, names of staff with signatures, that attended the training.
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Based on LPAs observations, record review the facility did not comply with the section cited above by not ensuring that the medication records were accurately maintained by staff when compared to medication given, which posed a potential health, safety or personal rights risk to persons 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.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Eldin Serrano
LICENSING EVALUATOR SIGNATURE:

DATE: 04/13/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/13/2026
LIC9099 (FAS) - (06/04)
Page: 4 of 4