<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 366426335
Report Date: 04/20/2021
Date Signed: 04/20/2021 11:41:46 AM



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
04/12/2021 and conducted by Evaluator Natalie Gayoso
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20210412120241
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: 49DATE:
04/20/2021
UNANNOUNCEDTIME BEGAN:
10:21 AM
MET WITH:Erwina AmoreTIME COMPLETED:
11:25 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility illegally evicted resident.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Natalie Gayoso 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 investigation consisted of interviews with staff and records review. The allegation indicates facility illegally evicted resident. LPA was infomed by administrator and assistant 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.

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: Natalie GayosoTELEPHONE: (951) 290-1102
LICENSING EVALUATOR SIGNATURE:

DATE: 04/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/20/2021
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-20210412120241
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: 04/20/2021
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
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 via email.
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Natalie GayosoTELEPHONE: (951) 290-1102
LICENSING EVALUATOR SIGNATURE:

DATE: 04/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/20/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 2