Villas At San Bernardino

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 andthe state’s words, verbatim · CDSS document, May 1, 2026 · control 56-AS-20251117144330

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

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 hallsthe state’s words, verbatim · CDSS document, Nov 13, 2025 · control 56-AS-20250821170913

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

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 althe state’s words, verbatim · CDSS document, Oct 27, 2025 · control 56-AS-20250620132232

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

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* Unsubstantthe 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. Unsubstantiatedthe 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 gatheredthe state’s words, verbatim · CDSS document, Dec 31, 2024 · control 56-AS-20241003160211

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. Unsubstantiatedthe state’s words, verbatim · CDSS document, Nov 21, 2024 · control 56-AS-20241107150903

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.