366426335-11-4-2022-56-AS-KCLS-CLES9D-20221122124034

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 366426335
Report Date: 11/04/2022
Date Signed: 11/04/2022 12:01:56 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
04/11/2022 and conducted by Evaluator Bernadette Allen

COMPLAINT CONTROL NUMBER: 56-AS-20220411083443

FACILITY NAME:	KNOLLS WEST ASSISTED LIVING		FACILITY NUMBER:	366426335
ADMINISTRATOR:	TERRONSAY WHALEY		FACILITY TYPE:	740
ADDRESS:	16890 GREEN TREE BLVD.		TELEPHONE:	(760) 245-0107
CITY:	VICTORVILLE	STATE: CA	ZIP CODE:	92395
CAPACITY:	64	CENSUS: 50	DATE:	11/04/2022
		UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Terronsay Whaley- Administrator		TIME COMPLETED:	12:15 PM

ALLEGATION(S):

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Staff threatened resident while in care.
Facility refused to let resident leave for higher level of care.

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPA) Bernadette Allen conducted an unannounced visit to the facility to investigate the above allegations and deliver findings. LPA Allen identified herself to administrator Terronsay Whaley and she was informed of the purpose of the visit.

The investigation consisted of facility file reviews, interviews with facility staff ,residents and relevant parties.

Allegation #1- Staff threatened resident while in care. Based on interviews with (8)eight residents,(4) four outside vendors/witnesses and (5) five staff members it has be deemed that (R1) was not threatened by the facility staff while in care.

Allegation #2-Facility refused to let resident leave for higher level of care. Based on interviews with (8)eight residents,(4) four outside vendors/witnesses, and (5) five staff members it has be deemed that the facility staff did not refuse to let (R1) leave the facility for a higher level of care.

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: 11/04/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2022

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-20220411083443

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: 11/04/2022

NARRATIVE

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Based on this information, LPA could not determine if the alleged incidents occurred or not. Although the allegations 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.

No deficiencies were cited during this visit.

An exit interview was conducted where this report was discussed and provided to the administrator Terronsay Whaley at the conclusion of the visit.

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Bernadette Allen	TELEPHONE: 951-897-2618
LICENSING EVALUATOR SIGNATURE:	DATE: 11/04/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2022

LIC9099 (FAS) - (06/04)

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