371881418-1-8-2026-18-AS-CTUA-DX9VEH-20260824162223

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 371881418
Report Date: 01/08/2026
Date Signed: 01/08/2026 01:52:45 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE 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
12/30/2025 and conducted by Evaluator Janira Arreola

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20251230090726

FACILITY NAME:	VILLA BERNARDO		FACILITY NUMBER:	371881418
ADMINISTRATOR:	LYNN DRUMMOND		FACILITY TYPE:	740
ADDRESS:	2960 BERNARDO AVE		TELEPHONE:	(858) 925-8858
CITY:	ESCONDIDO	STATE: CA	ZIP CODE:	92029
CAPACITY:	10	CENSUS: 10	DATE:	01/08/2026
		UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Staff, Karen Pangilinan		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Staff do not ensure that resident's toileting needs are being met while in care.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Janira Arreola, conducted an unannounced visit to the facility in order to investigate the above allegations. LPA met with Staff, Karen Pangilinan and spoke with Licensee and Administrator over the phone were was informed of the purpose of the visit. During the visit, LPA conducted interviews, documented observations/conducted a walk through, and conducted records review.

“Staff do not ensure that resident's toileting needs are being met while in care.”

It was alleged Resident #1 (R1) is not being assisted to their walker to use the restroom and that R1 has to evacuate their bowels in bed.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Carolyn Tuba
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE:	DATE: 01/08/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/08/2026

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-20251230090726

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: VILLA BERNARDO	FACILITY NUMBER: 371881418
	VISIT DATE: 01/08/2026

NARRATIVE

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R1’s LIC602 Physician’s Report dated 08/18/2025 revealed R1 is non ambulatory and facility care plan dated 09/22/205 documented R1 needs assistance with transfers and turning and using a wheelchair.

R1’s Home Health care plan dated 11/01/2025 revealed R1 has a pressure injury and physical limitations with ambulation. The home health care plan indicates R1 is up as tolerated, requires assistance with transfers from bed to chair, is partial weight bearing, and is provided with both a walker and a wheelchair.

R1 was interviewed on 11/25/2025, who stated they previously used a walker, however they are no longer physically able to. R1 reported they use a wheelchair with staff assistance. R1 self reported due to pain and physical limitations of a pressure injury on their bottom, they are not able to turn and reposition in bed without staff assistance. R1 demonstrated difficulty repositioning and turning to LPA. R1 reported staff regularly change their diaper, however R1 also stated staff does not assist R1 out of bed when requested.

LPA interviewed (3) facility staff 11/25/2025, who revealed R1 does not currently use a walker and uses a wheelchair with assistance. (3) of (3) staff reported R1 often declines being placed in their wheelchair and does not wish to get out of bed. During facility visit 01/08/2026 LPA observed R1 in their wheelchair and assisted to the dinning table by staff. All staff interviewed stated they provide in bed toileting when R1 refuses to get out of bed. All staff interviewed stated R1 is unable to turn in bed without assistance and R1 has a pressure injury on their coccyx. Interview with R1’s responsible party revealed R1 is bedbound, cannot ambulate with a walker, and R1 is primarily bedbound due to physical limitations and their pressure injury.

Therefore, based on interviews and records review, the allegation that are not meeting R1’s toileting needs while in care is unsubstantiated. There is no preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. An exit interview was conducted, and a copy of this report was provided.

SUPERVISORS NAME: Carolyn Tuba
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE:	DATE: 01/08/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/08/2026

LIC9099 (FAS) - (06/04)

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