Villas at San Bernardino

We haven’t transcribed this report yet. The complete document is on the state’s site.

Allegation investigated: Resident developed a parasitic infection due to staff neglect.

On 05/01/2026 at 9:30AM Licensing Program Analyst (LPA) Renese Howell-Small arrived unannounced to the facility to conclude the investigation and deliver findings for the above allegation. LPA introduced self and was greeted by staff. LPA met with Administrator,Yvette Navarro and Exective Director, Jacqueline Cortez, and discussed the purpose of the visit. The investigation consisted on interviews and record review. The allegation that resident developed a parasitic infection due to staff neglect: LPA interviewed ten (10) staff. Staff stated that they observe any change in a resident's condition, document it and report it to a supervisor.Resident 1 (R1) recieved wound care through a health agency on a weekly basis. R1 last received care from the health agency on 11/12/2025. R1 was sent to the hospital on 11/15/2025; the wound developed parasites. Based on interview and record review, this allegation is SUBSTANTIATED. SUBSTANTIATED is defined as the complaint allegation(s) is valid and a violation has occurred based on the preponderance of available evidence. A deficiency will be cited. An exit interview was conducted where this report LIC9099, LIC9099D and Appeal Rights were discussed, and copies wer provided to Executive Director, Jacqueline Cortez. Substantiatedthe state’s words, verbatim · CDSS document, May 1, 2026 · control 56-AS-20251117144330

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.725(a)(4) · Plan of correction due date: May 2, 2026

Incidental medical care 1569.725(a)(4) A residential care facility for the elderly may permit incidental medical services ...(4) There is ongoing communication... about the services provided... and the frequency and duration of care to be provided. This requirement was not met as evidenced by: Based on interview and a review of facility records, the facility did not ensure Resident 1 (R1) wound care was maintained by the health agency in which the wound developed parasites (maggots), which posed an immediate risk to the health and safety of the resident in care.the state’s words, verbatim · CDSS document, May 1, 2026

Plan of correction: The Administrator will conduct a training with staff regarding the non-medical care of wounds and will request a meeting with the health agency to discuss the required documentation for residents receiving wound care and will submit proof to LPA by Plan of Correction (POC) due date.

Allegation investigated: Staff handled a resident in a rough manner Staff refused to assist a resident in care Staff spoke to a resident in an aggressive manner

On 03/02/2026 at 9:15AM Licensing Program Analyst (LPA) Renese Howell-Small conducted an unannounced visit to the facility in order to deliver findings for the above allegations. LPA discussed the purpose of the visit with the Executive Director, Ruth Villa. The investigation consisted of interviews and record review. In regards to the allegation of staff handled a resident in a rough manner: LPA interviewed six (6) staff and nine (9) residents. Resident 1 (R1) was unable to give a specific example of how staff handled R1. Staff denied handling resident(s) in a rough manner and stated that R1 needs minmal assistance. Residents denied observing staff handle residents in a rough manner. Based on interviews, this allegation is UNSUBSTANTIATED. In regards to the allegation of staff refused to assist a resident in care: LPA interviewed residents and staff. Staff stated that all residents are assisted when needed and denied the allegation. Unsubstantiated Residents stated that staff assist them with their needs and respond to their call buttons. Based on interviews, this allegation is UNSUBSTANTIATED. In regards to the allegation of staff spoke to a resident in an aggressive manner: LPA interviewed residents and staff. Staff stated that they may increase their auditory volume when speaking with certain residents. Staff denied speaking in an aggressive manner. R1 stated that staff are nice and helpful. Based on interviews. this allegation is UNSUBSTANTIATED. UNSUBSTANTIATED is defined as the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation(s) occurred. An exit interview was conducted where this report LIC9099 and, LIC9099C was discussed and copies were provided to Community Liason Director, Crystal Wilkins.the state’s words, verbatim · CDSS document, Mar 2, 2026 · control 56-AS-20260205170106

Type of visit: Case Management - Deficiencies

On 03/02/2026 at 3:00PM Licensing Program Analyst (LPA) Renese Howell-Small arrived unannounced to the facility in order to conduct a Case Management visit. LPA met with Executive Director, Ruth Villa and stated the purpose of the visit. LPA toured both the assisted living and memory care units. LPA observed several resident bathrooms in the memory care unit to be unsanitary. A deficiency will be cited. An exit interview was conducted where this report LIC809, LIC809D and Appeal Rights were discussed and copies were provided to Community Liason Director, Crystal Wilkins.the state’s words, verbatim · CDSS document, Mar 2, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87303(a)(1) · Plan of correction due date: Mar 3, 2026

87303 (a) (1) Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times... (1) Floor surfaces in bath...shall be maintained in a clean, sanitary, and odorless condition. This requirement was not met as evidenced by: Based on interview and observation, the Licensee did not ensure that the resident bathrooms in the memory care unit were kept clean, which posed an immediate risk to the health and safety of residents in care.the state’s words, verbatim · CDSS document, Mar 2, 2026

Plan of correction: The staff cleaned the memory care unit restrooms during the visit. The Licensee/Administrator will develop and implement a back-up plan for maintanenance/housekeeping when staff are out and submit proof to LPA by Plan of Correction (POC) due date.

Type of visit: Case Management - Other

On 11/17/2025 at 1:15PM Licensing Program Analyst (LPA) Renese Howell-Small arrived unannounced visit to the facility in order to conduct a Case Management visit regarding complaint # AS-56-20251004194649. LPA was greeted by staff, granted entrance and met with Resident Services Director, Dulce Allen. LPA had planned to interview Resident 1 (R1), however the resident had been sent out to the hospital earlier that day. LPA conducted interviews with three (3) staff and obtained additional supportive documentation for the above complaint number. An exit interview was conducted where this report LIC809 was discussed and a copy was provided to staff.the state’s words, verbatim · CDSS document, Nov 17, 2025

Allegation investigated: The facility does not have enough staff for care and supervision of the residents in care The facility is dirty in memory care The laundry services were not done for the residents The facility does not provide showers for residents

On 11/13/025 at 10:00AM Licensing Program Analyst (LPA) Renese Howell-Small conducted an unannounced visit to the facility in order to deliver findings for the above allegations. LPA discussed the purpose of the visit with Resident Services Director, Dulce Allen. The investigation consisted of interviews, observation and record review. In regards to the allegation of the facility does not have enough staff for care and supervision of the residents in care: LPA interviewed six (6) staff and reviewed the staffing schedule. Staff stated that there is sufficient staff and when a staff is out, they work as a team to care for residents. The facility is staffed based upon the level of care of the residents. Based on interviews and record review this allegation is UNSUBSTANTIATED. In regards to the allegation of the facility is dirty in memory care: LPA interviewed six (6) staff, reviewed the housekeeping schedule and observed that upon each visit to the facility, staff were cleaning the halls, resident rooms and bathrooms. Based upon interviews and observation, this allegation is UNSUBSTANTIATED. Unsubstantiated In regards to the allegation of the laundry services were not done for the residents: The facility's Admission's Agreement states that they will provide laundry services once per week or more if needed. Staff stated that they launder the residents' items weekly and as needed. LPA observed that Resident 1 (R1) did not have any laundry in their hamper during today's visit. Based upon interview and observation, this allegation is UNSUBSTANTIATED. In regards to the allegation of the facility does not provide showers for residents: LPA reviewed R1's care plan and the facility's shower log. R1 has two (2) showers planned each week. However, a review of the shower log revealed that R1 has refused showers. Based upon record review, this allegation is UNSUBSTANTIATED. UNSUBSTANTIATED is defined as the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted where this report LIC9099 and LIC9099C was discussed and a copies were provided to Resident Services Director, Dulce Allen.the state’s words, verbatim · CDSS document, Nov 13, 2025 · control 56-AS-20250821170913

Type of visit: Case Management - Deficiencies

On 11/13/2025 at 3:30PM Licensing Program Analyst (LPA) Renese Howell-Small conducted an unannounced visit to the facility in order to conduct a Case Management - Deficiencies visit. LPA met with Resident Services Director, Dulce Allen. LPA conducted a tour of the memory care unit and observed that the "planned social and recreational programs" were limited. LPA observed the residents to be watching television and a few residents walking in the outdoor courtyard. LPA did not observe any activities provided for interaction and cognitive stimulation. A deficiency will be cited. An exit interview was conducted where this report LIC809, LIC809D and Appeal Rights were discussed and copies provided to the Resident Services Director.the state’s words, verbatim · CDSS document, Nov 13, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87219(a)(1) · Plan of correction due date: Nov 14, 2025

87219 Planned Activities(a)(1) Residents shall be encouraged to maintain and develop their quality of life through participation in a variety of planned activities. The activities made available... This requirement is not met as evidenced by: Based upon observation and interview, LPA observed the residents to be watching television and did not have any other activities available, which posed/poses an immediate risk to the health and safety of residents in care.the state’s words, verbatim · CDSS document, Nov 13, 2025

Plan of correction: The Administrator will create an activity calendar, plan and implment these activities for memory care residents and submit proof to LPA by Plan of Correction (POC) due date.

Allegation investigated: Due to lack of supervsioin, resident was assaulted by another resident resulting in injury

On 10/27/2025 at 10:00AM Licensing Program Analyst (LPA) Renese Howell-Small conducted an unannounced visit to the facility in order to deliver findings for the above allegation. LPA discussed the purpose of the visit with Executive Director, Kenya Carlton. The investigation consisted of interviews and record review. The allegation of due to lack of supervsioin, resident was assaulted by another resident resulting in injury: LPA interviewed the relative of Resident 1 (R1) and four (4) staff. The relative of R1 stated that they do not have any concerns with the facility and R1 is safe. Staff denied the allegation and stated that staff were available to assist the residents. The facility reported the incident to the Department and a report was filed with law enforcement. Based on interviews and record review, this allegation is UNSUBSTANTIATED. UNSUBSTANTIATED is defined as the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted where this report LIC9099 was discussed and a copy was provided to Executive Director, Kenya Carlton. Unsubstantiatedthe state’s words, verbatim · CDSS document, Oct 27, 2025 · control 56-AS-20250620132232

Type of visit: Case Management - Other

On 10/27/2025 Licensing Program Analyst (LPA) Renese Howell-Small conducted an unannounced Case Management visit in order to test the smoke alarm and fire system. LPA was greeted by staff and granted entrance into the facility. LPA introduced self and stated the purpose of the visit. LPA met with Ben Cruz in the maintenance department and initiated the test of the fire/smoke alarm system. An announcement was made to the residents that the system would be tested. LPA observed staff use the canister of smoke to trigger the system. During the test, the alarm sounded along with the flashing lights throughout the facility, the automatic doors closed and remained shut during the test. LPA observed the system to be working properly. An exit interview was conducted, where this report LIC809 was discussed and copy provided to Executive Director, Kenya Carlton.the state’s words, verbatim · CDSS document, Oct 27, 2025

Type of visit: Required - 1 Year

On 10/20/2025 at 9:15AM , Licensing Program Analyst (LPA) Renese Howell-Small arrived unannounced to conduct the required annual visit to the facility. LPA was greeted and granted entrance to the facility. LPA met with Executive Director, Kenya Carlton, Dulce Allen and Yvette Navarro and introduced self and stated the purpose of the visit. The facility is operating as a Residential Care Facility for the Elderly. The total capacity is 144 residents; there are currently 91 residents in care. The facility has a dining area for all residents and adequate seating. LPA completed a walk through of the facility with Dulce Allen, review of records and medication(s) audit. Physical Plant: The facility is operating in the capacity approved by Community Care Licensing Division (CCLD). There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature of 75 degrees Fahrenheit. LPA inspected ten (10) resident units in both the memory care unit and assisted living; they are equipped with the required furniture such as: mattresses, night stands, storage space, chairs and sufficient lighting. LPA inspected resident bathrooms; bathrooms were clean and appliances were found functional. Water temperatures tested at 115 degrees Fahrenheit. The facility is equipped with carbon monoxide alarms in each of the hallways on both levels, charged fire extinguishers and first aid kit, with book. A third party services both the fire extinguishers and the smoke alarm; last tested on 09/03/2025. Postings: Posters such as; the personal rights, emergency disaster plan, CCLD complaint poster and ombudsman were posted in a common area. Cleaning supplies, toxins, sharps, and other dangerous items were kept locked and inaccessible to residents. There was a designated storage space for resident/staff files. Medications were observed to be locked, inaccessible to residents in the medications room on the first level. There is no swimming pool, firearms or ammunition in the facility. Overall, the facility is clean, in good repair, and operating in safe conditions for residents in care. Food Service: Non-perishable and perishable food supply is sufficient for residents in care. Dishes, cups, and utensils were also stored properly. Yards/Outside: The facility has several shaded areas and courtyards throughout the facility with adequate seating. Record Review: LPA reviewed five (5) staff files for First Aid/CPR certification, criminal record clearance, training(s), and health screenings. LPA reviewed ten(10) resident files for admission agreements, updated physician reports, and needs and services plans. Three (3) deficiencies were cited during this visit. An exit interview was conducted where this report LIC809, LIC809C, LIC809D, and Appeal Rights were discussed and copies were provided to Executive Director, Kenya Carlton..the state’s words, verbatim · CDSS document, Oct 20, 2025

Allegation investigated: Staff does not keep resident’s room free from bed bugs Staff does not have enough bed linens for residents Staff does not keep residents bathroom clean

On 10/10/2025 at 9:10AM Licensing Program Analyst (LPA) Renese Howell-Small conducted an unannounced visit to the facility in order to deliver findings for the above allegations. LPA discussed the purpose of the visit with Executive Director, Kenya Carlton. The investigation consisted of interviews observation and record review. In regards to the allegation of Staff does not keep resident’s room free from bed bugs: LPA interviewed staff and residents. LPA observed the invoice from Ecolab dated 08/25/2025 which serviced the facility for bed bugs and the invoice dated 09/05/2025 did not find bed bug activity. Residents stated that the facility took care of the pests. Based on interviews and record review, this allegation is UNSUBSTANTIATED. In regards to the allegation of staff does not have enough bed linens for residents: LPA interviewed staff and observed and observed an adequate supply of linen in the laundry room on the first floor of the facility. *Continued on LIC9099C* Unsubstantiated LPA observed a sample of resident rooms and all of the rooms had linen on their beds and extra linen in their closets. Based upon interviews and observation, this allegation is UNSUBSTANTIATED. In regards to the allegation of staff does not keep residents bathroom clean: LPA interviewed staff and residents. Staff stated that rooms are cleaned once a week or more if needed. LPA observed a sample of resident rooms and bathrooms were clean. LPA also observed housekeeping staff and their cleaning carts with supplies during the visit. Based upon interviews and observation, this allegation is UNSUBSTANTIATED. UNSUBSTANTIATED is defined as the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation(s) occurred. An exit interview was conducted where this report LIC9099, LIC9099C was discussed and a copy was provided to the Executive Director.the state’s words, verbatim · CDSS document, Oct 10, 2025 · control 56-AS-20250825103602

Allegation investigated: Facility staff yell at residents Facility staff are not meeting residents toileting needs

On 03/26/2025 at 9:11AM Licensing Program Analyst (LPA) Renese Howell-Small conducted an unannounced visit to the facility to deliver findings for the above allegations. LPA was greeted by staff and granted entrance to the facility. LPA met with Executive Director, Kenya Calrton and discussed the purpose of the visit. In regards to the allegation that facility staff yell at residents: LPA interviewed six (6) staff, a relative of Resident 1 (R1) and interviewed R1. All staff denied that staff yell at residents in care. Staff have recieved several trainings regarding Resident Rights and Working with Challenging Residents. In an interview with R1 on 03/03/2025, R1 denied that staff yelled at residents. Based upon interview and record review, this allegation is UNSUBSTANTIATED. Unsubstantiated In regards to the allegation that facility staff are not meeting residents toileting needs: LPA interviewed six (6) staff and interviewed R1. R1 stated that there are no concerns and staff are meeting R1's needs. Every shift, staff complete two (2) hour checks to assist with toileting, grooming and showering needs beginning with residents who require full assistance with care and then assist the remaining residents. Facility notes confirm that R1 frequently uses the call button for assistance with toileting but may refuse assistance, then requests a different caregiver. Staff denied facility staff are not meeting residents toileting needs. R1's Admission's Agreement indicates that R1 receives full assistance with toileting needs. Based upon interview and record review, this allegation is UNSUBSTANTIATED. UNSUBSTANTIATED is defined as the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted where this report LIC9099, LIC9099C was discussed and a copy was provided to Executive Director, Kenya Carlton.the state’s words, verbatim · CDSS document, Mar 26, 2025 · control 56-AS-20250224112022

Allegation investigated: Staff mismanaged resident medication

On 12/31/2024 at 9:15AM Licensing Program Analyst (LPA) Renese Howell-Small conducted an unannounced visit to the facility and met with Executive Director, Kenya Carlton for the purpose of delivering findings for the above allegation. LPA was greeted by staff, introduced self and stated the purpose of the visit. Regarding the allegation of staff mismanaged resident medication and based on an in-person interview with Executive Director, Kenya Carlton LPA Small confirmed that Resident #1 (R1) went to the hospital on 09/28/2024 and was released on 09/29/2024. Once R1 was released at 4:00PM on 09/29/2024, R1's discharge papers were faxed the same day but did not include a copy of the prescription. As a result R1 did not receive and was not given the prescribed medication until 10/01/2024. LPA interviewed staff, audited R1's MAR for the months of September and October, reviewed the Unsual Incident/Injury Report (SIR) and the discharge notes from the physician. Based on the evidence gathered during the investigation and in accordance with Title 22 regulation 87465 (a) (2), the above allegation is SUBSTANTIATED. Substantiated SUBSTANTIATED is defined as The “preponderance of the evidence” standard has been met. A deficiency was cited. An exit interview was discussed and a copy of this report, LIC9099, LIC9099C, LIC9099D and Appeal Rights was left with Executive Director, Kenya Carlton.the state’s words, verbatim · CDSS document, Dec 31, 2024 · control 56-AS-20241003160211

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(2) · Plan of correction due date: Jan 2, 2025

87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility... (2) Once ordered... given according to physician's directions. This standard was not met as evidenced by: Based on interview, obervation and record review theLicensee/Administrator did not comply with the section cited above by not ensuring that medication was given to resident #1 (R1) in care after (R1) returned from the hospital, which poses an immediate health, safety, or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Dec 31, 2024

Plan of correction: Licensee/Administrator has agreed to conduct Medication Training on CCR 87465(a)(2) to all staffs dispensing medications to residents and submit proof to LPA Howell-Small on Plan of Correction (POC) due date.

Allegation investigated: Staff do not serve quality food to residents.

First Complaint: Licensing Program Analyst (LPA) Beena Singh conducted an unannounced visit to deliver findings on the allegations listed above. LPA met with Facility Administrator Kenya Carlton and explained the purpose of the visit. The investigation consisted of interviews and review of records. First Allegation, Staff do not serve quality food to residents. During interviews with residents, 5 out of 5 residents denied being not serving quality food to residents. All 5 out of 5 residents are happy with choices and quality of food being served at the facility. LPA conducted an interview with Resident #1 who reported to LPA that resident has been looked after by the staff and food service is good. R#1 stated she always has been given good food choices and quality of food is good to better. Unsubstantiated Based on the evidence found during the investigation, LPA Beena Singh found the allegation listed above to be Unsubstantiated. Unsubstantiated: A finding that the complaints are Unsubstantiated means although the allegation may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. During today’s visit, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted, and this report was discussed and provided to Facility Administrator Kenya Carlton.the state’s words, verbatim · CDSS document, Nov 21, 2024 · control 56-AS-20241107150903

Type of visit: Prelicensing

On 09/20/2024 a 9:20AM, Licensing Program Analysts (LPAs) Renese Howell-Small and Melody Brown conducted an announced visit to the facility for the purpose of a Change of Ownership evaluation. LPAs Howell-Small and Brown met with Administrator Kenya Carlton. An initial application for change of ownership to operate a Residential Care for the Elderly facility (RCFE) was submitted to the Central Applications Bureau (CAB) on 01/04/2024 for a total capacity of one hundred forty-four (144) . Fire clearance was granted on 05/16/2024 for 114 non-ambulatory and 30 bedridden residents, with a total capacity of 144. LPAs Howell-Small and Brown observed the following: Structure: Facility was a two-level with seventy-nine (79) resident bedrooms, seventy-nine (79) resident bathrooms and four (4) staff bathrooms, living room, dining area and kitchen. There was no attached car garage but have a parking lot on the south side of the facility. Heating/Cooling System: Central heating and air conditioning system installed with a central panel located in the hallway to control the entire facility. Bedrooms: Each resident bedrooms accommodate any non-ambulatory resident. All resident bedrooms were adequately furnished with bed, chair, closet, appropriate linens, adequate lighting, and an operable smoke alarm. Bathrooms: The seventy-nine (79) resident bathrooms have a working toilet, wash basin, and shower with an adequate supply of toilet paper and soap. At 10:30 AM, LPAs tested the water temperatures in the resident bathrooms. LPAs verified water temperature was measured at 116 degrees Fahrenheit. ***CONTINUED ON LIC 809C*** ***CONTINUED FROM LIC 809*** Kitchen/Laundry: An adequate supply of dishes, glasses, utensils, pots, and pans were observed. Knives/sharp instruments were secured in a locked drawer located in the kitchen. There was adequate room for food storage. LPAs observed the stove to be operational. Refrigerator/freezer were in working condition. There is more than seven (7) days’ supply of non-perishable foods and more than two (2) days’ supply of perishable foods. There was adequate seating for meals for all residents. Laundry room with washer and dryer on both levels of the facility. Laundry detergents and cleaning supplies are stored in the chemical storage room. Living/Family room: There was a living/family room with adequate seating for all residents and a working TV. Linens and Hygiene Supplies: An adequate supply of linens was stored in a cabinet in the main hallway of the facility. Yards/Outside: Patio furniture for outdoor seating observed. Gates on both side of the facility. All outdoor pathways were free of obstructions. Emergency Phone Numbers, and Exit Plan: Facility sketch were observed posted in the dining room and hallways. There was an Ombudsman poster and Let-Us-No poster and Personal RIghts observed. General items: Nineteen(19) fire extinguishers were charged and located throughout the facility. Smoke alarms and carbon monoxide detectors were tested and were observed to be in working order. Resident records were stored in a locked cabinet in the office room. First Aid kit with required components, and locked area for medication storage was observed. LPAs observed a facility phone and was operational as evidenced by LPAs dialing the number. The phone number designated for the facility is (909) 883-7703. There is enough Emergency water supply observed and the required 72-hour emergency food supply was observed from the regular food supply. Component III was completed on this day as well. ***CONTINUED FROM LIC 809C** Additionally, LPAs observed facility to have required single entry point upon entering the facility. LPAs observed activities for the residents such as books and games. The facility was evaluated in accordance with the CCR, Title 22, Division 6, Chapters 1 and 6 to ensure the health and safety of residents in care. Facility appears to be ready for licensure. An exit interview was conducted, and a copy of this report, LIC809 and LIC9102 were reviewed and provided to Administrator Kenya Carlton.the state’s words, verbatim · CDSS document, Sep 20, 2024

The state marks this report as 4 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.