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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 366426335
Report Date: 12/09/2024
Date Signed: 12/09/2024 11:33:13 AM

Unfounded


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
12/04/2024 and conducted by Evaluator Eldin Serrano
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20241204160217
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:
12/09/2024
UNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Terronsay Whaley, AdministratorTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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9
Staff does not ensure resident is provided meal service in a timely manner.
Staff does not ensure medications are dispensed as prescribed for resident in care.
INVESTIGATION FINDINGS:
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On 12/09/2024 at 9:20 AM, Licensing Program Analyst (LPA) Eldin Serrano conducted an unannounced visit to the facility to commence a complaint investigation. LPA Serrano was greeted and granted entrance by a staff member and LPA Serrano met with the administrator Terronsay Whaley. LPA Serrano identified himself and discussed the purpose of the visit and the elements of the allegations with administrator Whaley. LPA Serrano conducted a quick tour of the facility, interviewed staff, and obtained facility records.

Regarding allegation "Staff does not ensure resident is provided meal service in a timely manner." LPA Serrano reviewed facility documents and conducted interview with the administrator. Per resident's roster review and interviews conducted, LPA Serrano determined Resident #1 (R1) does not live at this facility. LPA was able to verify that R1 lives at another facility nextdoor that is a skilled nursing facility (Knolls West Post Acute) that resembles the name of this facility and shared the same address.

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

DATE: 12/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2024
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-20241204160217
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: 12/09/2024
NARRATIVE
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Regarding allegation “Staff does not ensure medications are dispensed as prescribed for resident in care.” LPA Serrano reviewed facility documents and conducted interviews with relevant parties. Per documents (resident's roster) review and interviews conducted, LPA Serrano determined Resident #1 (R1) lives at another facility. During the visit today, 12/09/2024 LPA Serrano was able to verify that R1 lives at another facility nextdoor that is a skilled nursing facility (Knolls West Post Acute) that resembles the name of this facility and shared the same address.

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Therefore, Staff does not ensure resident is provided meal service in a timely manner.(Allegation #1) and Staff does not ensure medications are dispensed as prescribed for resident in care. (Allegation #2) are UNFOUNDED.

This agency has investigated the complaint allegations. 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. We have therefore dismissed the complaint.



An exit interview was conducted with administrator Terronsay Whaley and a copy of this report, LIC9099 was discussed and provided.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Eldin Serrano
LICENSING EVALUATOR SIGNATURE:

DATE: 12/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2