366426335-10-12-2022-56-AS-KCLS-CKAUK6-20221017153833

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 366426335
Report Date: 10/12/2022
Date Signed: 10/12/2022 02:10:58 PM

Unsubstantiated

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
, CA 92507

This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/03/2022 and conducted by Evaluator Bernadette Allen

COMPLAINT CONTROL NUMBER: 56-AS-20221003140246

FACILITY NAME:	KNOLLS WEST ASSISTED LIVING		FACILITY NUMBER:	366426335
ADMINISTRATOR:			FACILITY TYPE:	740
ADDRESS:	16890 GREEN TREE BLVD.		TELEPHONE:	(760) 245-0107
CITY:	VICTORVILLE	STATE: CA	ZIP CODE:	92395
CAPACITY:	64	CENSUS: 51	DATE:	10/12/2022
		UNANNOUNCED	TIME BEGAN:	09:10 AM
MET WITH:	Terronsay Whaley Administrator		TIME COMPLETED:	02:15 PM

ALLEGATION(S):

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Staff does not provide meals to non-ambulatory residents
Staff do not meet toileting needs for residents
Staff are not bathing residents
Facility lacks adequate staffing to meet residents needs
Staff leave non-ambulatory residents in their beds all day
Staff restrains resident in bed all day
Staff do not permit residents to participate in activities
Staff verbally abuses clients

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Bernadette Allen conducted an unannounced visit to initiate a complaint investigation for the allegation(s) listed above. LPA Allen met with the administrator Terronsay Whaley and she was informed of the purpose of the visit and the allegations listed above.

Based on interviews,observations and record reviews LPA, Allen observed the following.

Allegation #1 Staff does not provide meals to non-ambulatory residents
LPA Allen observed staff members ensuring that the non-ambulatory residents needs are being met. During the visit LPA observed amblulatory and non-ambulatory residents being feed during the visit.

Allegation #2 Staff does not meet toileting needs for residents
LPA interviewed staff and residents based on the interviews the staff are ensuring that the residents toileting needs for the residents are being met. LPA observed record review during the visit.

Allegation #3- Staff are not bathing residents
LPA interviewed staff, residents, and record review based observations and interviews the staff are ensuring that the residents bathing needs are being met by the staff.

Allegation #4- Facility lacks adequate staffing to meet residents needs
LPA interviewed staff, reviewed records and observed that there was adequate staffing and that the resident’s needs were being met.

Allegation #5- Staff leave non-ambulatory residents in their beds all day and
Allegation #6- Staff restrains resident in bed all day.
LPA interviewed staff, residents and observed non-ambulatory residents who were not in their beds LPA also reviewed residents’ files and based on observations residents are not being restrained in bed all day.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Bernadette Allen	TELEPHONE: 951-897-2618
LICENSING EVALUATOR SIGNATURE:	DATE: 10/12/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 56-AS-20221003140246

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
, CA 92507

FACILITY NAME: KNOLLS WEST ASSISTED LIVING	FACILITY NUMBER: 366426335
	VISIT DATE: 10/12/2022

NARRATIVE

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Allegation #7- Staff does not permit residents to participate in activities
LPA interviewed staff, residents and observed that residents can and were participating in activities.

Allegation #8 - Staff verbally abuses clients
LPA interviewed staff and residents based on these interviews the staff does not verbally abuse clients.

During the investigation LPA reviewed documents, interviewed staff and residents and based on the investigation the allegations may have happened or are valid, there is not a preponderance of evidence to prove the all above alleged violations did or did not occur, therefore the allegations are unsubstantiated at this time.

An exit interview was conducted where this report was discussed and provided to Terronsay Whaley Administrator

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Bernadette Allen	TELEPHONE: 951-897-2618
LICENSING EVALUATOR SIGNATURE:	DATE: 10/12/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2022

LIC9099 (FAS) - (06/04)

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