366426413-5-6-2026-18-AS-CTUA-DU7VFL-20260518162407

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 366426413
Report Date: 05/06/2026
Date Signed: 05/06/2026 01:38:59 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
05/05/2021 and conducted by Evaluator Jacqueline Shaw Ross

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20210505155953

FACILITY NAME:	APPLE GARDEN SENIORS		FACILITY NUMBER:	366426413
ADMINISTRATOR:	GEORGE KARKALETSIS		FACILITY TYPE:	740
ADDRESS:	12994 RINCON RD.		TELEPHONE:	(760) 240-2600
CITY:	APPLE VALLEY	STATE: CA	ZIP CODE:	92308
CAPACITY:	6	CENSUS:	DATE:	05/06/2026
		UNANNOUNCED	TIME BEGAN:	11:40 AM
MET WITH:	Gloria Dupio, Caregiver		TIME COMPLETED:	01:40 PM

ALLEGATION(S):

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Neglect of a resident resulting in serious bodily injury.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA Jacqueline Shaw-Ross made an unannounced visit to deliver findings for the allegation listed above. LPA met with Gloria Dupio, Caregiver and explained the purpose of the visit. LPA also spoke with Administrator, George Karkaletsis, by telephone and the purpose of the visit was explained. The investigation consisted of observations, interviews and a review of documentation.

On 05/05/2021, the Department received a complaint alleging neglect of a resident resulting in serious bodily injury. It was reported that on 05/04/2021, Resident 1 (R1) fell from the toilet and struck their head on the bathtub resulting in lacerations. It was reported R1 resided at the facility for six months and had six (6) falls.

On 05/07/2021, a video visit was conducted where R1 was observed to have purple -colored bruises located around their right eye and on top of their nose, a cut above their eyebrow, and approximately four (4) visible butterfly stitches above R1’s right eyebrow, as well as gauze on the right side of their forehead.
The interview of R1 was not successful due to R1’s cognitive impairment. The Administrator reported that two staff members were on duty at the time of the 05/04/2021 incident: the Administrator and Staff 1 (S1).
Continue on LIC 9099-C....

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Jacqueline Shaw Ross
LICENSING EVALUATOR SIGNATURE:	DATE: 05/06/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2026

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 18-AS-20210505155953

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: APPLE GARDEN SENIORS	FACILITY NUMBER: 366426413
	VISIT DATE: 05/06/2026

NARRATIVE

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According to the administrator, S1 was “either in the kitchen or in R1’s bedroom” and responded immediately when called to the bathroom. An interview with S1 was attempted but not successful.

The administrator explained R1 could only be transferred using a back and forth motion and was unable to grasp the toilet’s side handles for support. A review of R1’s physician’s report dated 07/09/2018 revealed R1 was non ambulatory and unable to manage toileting independently but did not indicate whether a two person assist was required. The Resident Appraisal dated 06/30/2018 was reviewed and the section for toileting assistance was left blank. Hospice progress notes, dated 04/13/2021, documented that R1 required maximum assistance, was incontinent, nonverbal, unable to follow commands, and exhibited significant weaknesses. Hospice Care Coordination notes, dated 04/23/2021 and 04/19/2021, documented R1 required “Max Assist for cares such as bathing, dressing, incontinence cares, positioning, transfer, and feeding,” but did not specify whether a two person assist was required. The administrator reported it was a “normal fall” and stated the wheelchair had been placed to R1’s left side by the sink, after the administrator positioned R1 on the commode. The administrator reported taking their hands off R1 for only a few seconds before R1 fell, hitting their head on the shower edge and then falling to the floor.

It was reported that facility staff contacted hospice immediately. Hospice arrived within approximately 10 minutes, completed a visual assessment, and instructed staff to call paramedics. Attempts to locate and interview the hospice worker who responded were unsuccessful. Medical records from the day of the incident indicated R1 sustained two forehead lacerations, which were closed using Dermabond strips. R1 was released the same day and returned to the facility.

The report that R1 had experienced six falls since admission was investigated. However, only one fall—reported in April 2021—could be verified. That incident resulted in no injuries, and no additional documentation was available to corroborate the other alleged falls.

Based on observations, interviews, and a review of records, the allegation of neglect of a resident resulting in serious bodily injury is unsubstantiated. An unsubstantiated finding means the preponderance of evidence standard has not been met.

A copy of this report was reviewed and provided to Gloria Dupio, Caregiver.

SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Jacqueline Shaw Ross
LICENSING EVALUATOR SIGNATURE:	DATE: 05/06/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2026

LIC9099 (FAS) - (06/04)

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