Summerfield of Redlands

Type of visit: Case Management - Incident

Licensing Program Analysts (LPA) Edith Conchas conducted an unannounced visit to the facility for the purpose of a Health & Safety check. LPA identified them self to Rachelle Wheaton and discussed the purpose of the visit. Residents in care were present during visit. No imminent health and/or safety concerns observed at the time of visit. LPA observed no health and/or safety hazards inside the facility. LPA observed staff present at the facility to provide care. The needs of the residents in care appear to be met during this inspection. An exit interview was conducted where this report was discussed and provided to the Executive Director, Rachelle Wheatonthe state’s words, verbatim · CDSS document, Jul 30, 2026

Type of visit: Case Management - Other

On 6/26/2026 Licensing Program Analyst (LPA) Edith Conchas arrived to the facility to amend a complaint investigation report 56-AS-20250818130125 that was originally delivered on 5/5/2026. LPA met with Executive Director Rachelle Wheaton and was informed of the reason for the visit. LPA printed the report and conducted a tour of the facility. An exit interview was conducted where this report were discussed and a copy provided to Executive Director Rachelle Wheaton.the state’s words, verbatim · CDSS document, Jun 26, 2026

Allegation investigated: Staff leave residents unattended for extended periods Staff are not meeting resident's incontinence care needs Staff did not notify resident's representative of incident Untrained staff providing care to residents Staff did not prevent residents from engaging in a physical altercation Staff did not ensure resident's medication was properly stored

Licensing Program Analyst (LPA) Mary Rico conducted an unannounced visit to investigate and deliver findings on the allegations listed above. LPA met with Business Office Manager Jonathan Guzman and explained the purpose of the visit. The investigation consisted of staff interviews, resident interviews, medication audit and record review. For the allegation, Staff leave residents unattended for extended periods. During staff interviews, 4 out of the 4 staff stated they have not left their residents unattended for extended periods of time. During resident interviews, 3 out of the 6 residents stated they have not been left unattended. In addition, 3 out of the 6 remaining residents were unable to collaborate on the allegation. During facility tour, LPA Rico observed residents participating in activities and staff providing assistance with residents ADLs. Unsubstantiated For the allegation, Staff are not meeting resident's incontinence care needs. During staff interviews, 4 out of the 4 staff stated that they change their residents every two hours, and as needed. During resident interview, 3 out of the 6 residents stated that staff meet their incontinence needs. In addition, 3 out of the 6 remaining residents were unable to collaborate on the allegation. For the allegation, Staff did not notify resident's representative of incident. During staff interviews, 4 out of the 4 staff stated that residents’ representatives are notified when an incident occurs. During resident interviews, 6 out of the 6 residents were unable to collaborate on the allegation. For the allegation, Untrained staff providing care to residents. During staff interviews, 4 out of the 4 staff stated that training is provided. In addition, 4 out of the 4 staff stated that training is completed before assisting residents. During record review, LPA Rico observed staff have completed their training. For the allegation, Staff did not prevent residents from engaging in a physical altercation. During staff interviews, 4 out of the 4 staff stated that no altercation has occurred between residents. In addition, 4 out of the 4 staff stated they would redirect residents if an altercation were to occur. During resident interviews, 3 out of the 6 residents stated no altercation had occurred. In addition, 3 out of the 6 remaining residents were unable to collaborate on the allegation. For the allegation, Staff did not ensure resident's medication was properly stored. During staff interviews, 4 out of the 4 staff stated that medication is stored properly. During medication audit, LPA Rico observed all medications to be locked and stored properly. Based on the evidence found during the investigation, the six (6) allegations listed above are deemed UNSUBSTANTIATED. A finding that the complaints are UNSUBSTANTIATED means although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations 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 (LIC9099) was discussed and provided to Business Office Manager Jonathan Guzman.the state’s words, verbatim · CDSS document, Jun 19, 2026 · control 56-AS-20240529094451

Allegation investigated: Facility staff did not provide adequate supervision, resulting in non-consensual sexual behavior amongst residents. Facility staff did not notify authorized representative of incidents. Facility staff do not ensure residents are served food of good quality. Facility staff do not follow the facility menu. Facility staff did not safeguard residents’ belongings.

On 6/26/2026 Licensing Program Analyst (LPA) Edith Conchas conducted an unannounced visit to the facility to deliver the findings of the above allegations. LPA met and explained the purpose of the visit to Rachelle Wheaton. The investigation included interviews with staff, residents, witnesses, and review of facility records. Allegation: Facility staff did not provide adequate supervision, resulting in non-consensual sexual behavior amongst residents. Witness interviews indicated that this was the first time they had heard of Resident 3 (R3) engaging in the alleged behavior, and they questioned the credibility of the source. LPA attempted to interview (R1) and (R3) but was unsuccessful. Interviews with staff revealed that an in-house investigation was completed and that none of the staff observed any inappropriate conduct. Interviews with four residents confirmed that they had not witnessed any non-consensual sexual behavior among residents. Continue to LIC 9099-C Unsubstantiated Allegation: Facility staff did not notify authorized representative of incidents. Record review revealed that the incident was reported immediately to responsible parties, Witness 2 (W2) and (W4). LPA interviewed both witnesses and they confirmed that they were notified of the incident. Allegation Facility staff do not ensure residents are served food of good quality. LPA interviewed staff, residents, and witnesses and toured the kitchen. Staff reported that full meals are provided, including protein, starch, fruit, and side options. Three staff interviews confirmed that additional food is available in the cottages for staff to prepare for residents. Two witnesses stated that residents have food options available to them. Three residents reported that the food is good. During the visit, LPA observed that the lunch being served appeared to be of good quality. Allegation: Facility staff do not follow the facility menu. LPA interviewed staff and residents. Interviews with staff revealed they try to follow the menu as closely as possible. S5 and S4 stated that they do follow the menu items. Two residents and one witness reported that they do not pay attention to the menu. LPA observed that the lunch served matched the facility’s posted menu. Allegation: Facility staff did not safeguard residents’ belongings. Interview with staff revealed that R1’s items were found and returned to them. Interview with staff also revealed that the residents’ belongings are safeguarded by labelling their names on their clothing. LPA interviewed the families of R1, R2, and R3, residents belongings are safeguarded but residents do wander and sometimes will take items. Based on corroborating evidence obtained during the investigation, LPA has determined that the above allegations are Unsubstantiated. Unsubstantiated: meaning that although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. An exit interview was conducted where this report was discussed, and a copy was provided to Rachelle Wheaton, Executive Director at the end of the visit.the state’s words, verbatim · CDSS document, May 5, 2026 · control 56-AS-20250818130125

Type of visit: Case Management - Incident

On 5/5/2026, Licensing Program Analyst E. Conchas Licensing conducted an unannounced visit to this facility to follow up on Unusual Incident Report occurring on 4/20/2026. LPA meet with Executive Director, Rachelle Wheaton. Unusual incident report was that a care staff, during incontinence care observed R1 with an intact glove in her diaper. LPA conducted interview with Rachelle Wheaton regarding incident and conducted a health and safety check with resident involved. R1 was observed sleeping in room. No health concerns were observed at the time.the state’s words, verbatim · CDSS document, May 5, 2026

Type of visit: Required - 1 Year

On 4/10/2026 Licensing Program Analysts (LPAs) E. Conchas and A. Martinez conducted an unannounced visit to the facility for an annual inspection. LPAs met with Executive Director, Rachelle Wheaton, and explained the purpose of the visit. The facility is licensed to serve (75) residents. The facility has an approved hospice waiver for 12. The facility currently has 7 residents receiving hospice services. The facility is a single-story structure consisting of 4 cottages with individual rooms and restrooms, a kitchen, common area, patio area, dining area and a laundry room in cottage. There are no pools or bodies of water on the premises. The hot water temperature was tested and measured between 107.6 -114.2 degrees Fahrenheit. The facility was observed to be clean and clutter free. The facility was observed to have the required postings such as personal rights, CCL complaint and the Ombudsmen poster. The food supply was adequate as the facility has sufficient food supply for residents in care. However, LPAs did observe nonperishable food without expiration and perishable food with past due used by dates. A deficiency was cited. The medications and sharp objects were locked and inaccessible to residents. The facility is required to conduct the emergency disaster drills on a quarterly basis, the last drill was conducted for the month of February and March for the morning, evening and nocturnal shifts. Continue to LIC 809-C Record reviews were conducted on both staff and resident files. Files reviewed of residents were observed to have a medical assessment, and appraisals, physician reports and needs and service plan. Medications appeared to be dispensed appropriately according to MAR. LPAs observed staff records. Records of required staff have current CPR certification, with all staff having obtained proper fingerprint clearance and to be associated to the facility and with the required training. The Administrator was observed to have a valid administrator certificate, which expires 02/14/2028. LPA conducted a file review. Facility had a licensed contractor Johnson Controls Inc 436 inspection completed on December 2025 for the fire sprinkler and Fire Master completed inspection for the fire extinguishers and egress system completed in December 2025. The facility has fully charged fire extinguishers, and the smoke and carbon monoxide detectors were tested and were observed to be operable. Based on today's inspection one citation was issued in accordance with the California Code of Regulations (Title 22, Division 6, Chapter 8). An exit interview was conducted and a copy of this report, appeal rights, was provided to Executive Director, Rachelle Wheaton.the state’s words, verbatim · CDSS document, Apr 10, 2026

The state marks this report as 6 pages; the online copy we transcribed has 4. You can request the full file from the county licensing office.

Allegation investigated: Residents are being sexually abused due to staff neglect

On 03/27/2026 Licensing Program Analyst (LPA) LaVette Farlow conducted an unannounced visit to the facility to conclude the complaint investigation and deliver the findings of the above allegation. LPA Farlow met with Executive Director, Rachelle Wheaton. The investigation was conducted by the Department and consisted of record reviews and interviews with residents, staff, and relevant parties. On 08/07/2024 the department received a complaint alleging residents are being sexually abused due to staff neglect. It was reported by an unknown staff member that staff 1 (S1) was observed straddling an unknown resident. Interview with S5 revealed that an internal investigation was conducted and found the allegation to be a rumor. Interview with witness also revealed an investigation was conducted and the allegation was found to be a rumor and hearsay and did not rise to the level of further criminal investigation. The Department interviewed staff and staff interviews did not disclose that they observed S1 straddling a resident. Unsubstantiated It was alleged that on 8/2/2024 multiple staff reported that seven (7) dementia residents had reported being raped or inappropriately touched by S1. It is alleged that (R1) reported to (S2) that S1 touched them inappropriately. The Department interviewed residents, staff, and witnesses, and the allegation could not be corroborated. An interview was conducted with R1, during which a photo of S1 was shown. R1 did not recognize or recall S1. S1 was interviewed and denied any sexual abuse of residents. Interviews and record reviews indicated that S1 generally worked from 2 PM – 10 PM and was terminated from the position due to violation of company policy. According to S1 personnel records on 7/16/2024 and 7/25/2024 S1 was found lying in residents’ bed by themselves instead of assisting residents in the dining room. During the investigation it was documented that S5 conducted interviews with relevant parties and there wasn’t any documentation to support the allegation of sexual abuse by S1. Although S1 has a history of disciplinary action, none of the actions reviewed supports the allegations of sexual abuse. Although the allegation 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 Executive Director Rachelle Wheaton.the state’s words, verbatim · CDSS document, Mar 27, 2026 · control 56-AS-20240807172802

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) LaVette Farlow conducted an unannounced visit to this facility to conclude an complaint investigation. The complaint number: 56-AS-20240807172802. LPA met with Executive Director, Rachelle Wheaton. During the course of the investigation, the Department conducted interviews with clients, staff, and did a walk-through of the facility. The Department found the following issues: Administrator did not report to the Regional Office of the allegation of possible sexual abuse to residents in care. Administrator did not report to, licensing agency and to the person responsible for the resident within seven (7) days of the occurrence of any of the events specified. that there was an internal investigation regarding the allegations. Any suspected physical abuse that results in serious bodily injury of an elder or dependent adult shall be reported to the local ombudsman, the corresponding licensing agency, and the local law enforcement agency within two (2) hours as required by Welfare and Institutions Code Section 15630(b)(1) These pose an immediate and potential health and safety risk to residents in care. Refer to LIC 809D for deficiencies cited. An exit interview was conducted where this report LIC809, LIC809D, and appeal rights were discussed with and provided to Executive Director, Rachelle Wheaton.the state’s words, verbatim · CDSS document, Mar 27, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(1)(b) · Plan of correction due date: Apr 17, 2026

87211 Reporting Requirements A written report shall be submitted to the licensing agency..(b)Any suspected physical abuse that results in serious bodily injury of an elder or dependent adult shall be reported to the local ombudsman, the corresponding licensing agency, ...local law enforcement agency within two (2) hours as required by Welfare and Institutions Code Section. Based on observations, interviews and record review, the administrator did not comply with the section cited above by not submitting an incident report within 7 days of the incident which poses a potential health, safety and personal risk to persons in care.the state’s words, verbatim · CDSS document, Mar 27, 2026

Plan of correction: Executive Director stated that she will conduct a training and review the regulation with all staff and ensure to submit a statement of understanding with all participate to LPA via email by POC due date.

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) LaVette Farlow, arrived at facility to conduct an unannounced case management visit to this facility regarding an incident report received by the Department on 08/07/2024, control number 56-AS-20240807172802. LPA met Business Office Manager, Jonathan Guzman and explain the purpose of the visit. The following is a summary of LPA's visit: During the visit LPA conducted interviews with staff, reviewed facility records, and collected relevant documents to assist with the investigation. No deficiencies were cited during today’s visit. An exit interview was conducted where a copy of this report was provided to Business Office Manager, Jonathan Guzman.the state’s words, verbatim · CDSS document, Mar 6, 2026

Type of visit: Case Management - Other

On 3/6/2026, LPA E. Conchas made an unannounced case management visit to deliver amended report on complaint control number 56-AS-20250905080217. LPA originally delivered the complaint allegation findings on 2/24/2026. LPA met with Business Office Manager, Jonathan Guzman and was informed the reason for the visit. During this visit LPA also toured the facility, conducted interviews, assessed pertinent documents and obtained copies for complaint number 56-AS-20250818130125. An exit interview was conducted where this report were discussed and a copy was provided to Business Office Manager, Jonathan Guzman.the state’s words, verbatim · CDSS document, Mar 6, 2026

Allegation investigated: Resident sustained bruising due to an unknown cause.

On 2/24/2026 at 1:05 Licensing Program Analysts (LPA) E. Conchas conducted an unannounced visit to the facility to deliver the findings of the above allegation. LPA met and explained the purpose of the visit to Rachelle Llamas, Executive Director. The Department conducted an investigation into the allegation of resident sustained bruising due to an unknown cause. The investigation included interviews with staff, review of facility records, and review of medical documentation. Interviews conducted with staff revealed that R1 has a history of altercations with multiple residents. R1 frequently wanders into other residents’ rooms. Interview with staff revealed that on August 28, 2025, a hospice aide discovered bruises on R1 and notified staff 2(S2). Continue to LIC 9099-C Unsubstantiated On September 1, 2025, staff 1 (S1) observed additional bruises on R1 neck as R1 was leaving the facility with family. Review of staff notes indicated bruising may have occurred around the same time R1 had physical altercations with R2 on 08/27/2025 during the nocturnal shift. On September 1, 2025 R1 was taken to the hospital where bruising was confirmed; no fractures were noted. Document review revealed that between July 2, 2025, and August 2025, R1 prescription dosage increased from 20mg to 50mg indicating it was for behavioral management which occurred during the same time that R1 had multiple altercations with resident. Although bruising was observed, the Department could not determine the exact source of the bruising. Therefore, based on interviews conducted and records review, the allegation, resident sustained bruising due to an unknown cause is unsubstantiated. A finding that the complaint is UNSUBSTANTIATED means although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. An exit interview was conducted where this report was discussed, and a copy was provided to Rachelle Llamas, Executive Director.the state’s words, verbatim · CDSS document, Feb 24, 2026 · control 56-AS-20250905080217

The state marks this report as 5 pages; the online copy we transcribed has 2. You can request the full file from the county licensing office.

Allegation investigated: Staff did not properly supervise resident resulting resident to fall.

Licensing Program Analyst (LPA) Javier Prieto arrived to the facility to conclude a complaint investigation regarding the above allegation. LPA Prieto met with Executive Director Rachelle Llamas and explained the elements of the complaint. Allegation #1 - Executive Director Llamas (S1) produced medical assessment, for resident #1 (R1) in question, as well as the Needs and Services Plan, Face sheet and Narrative Charting notes. R1's assessment indicates that the diagnosis is related to R1's residence at a Memory Care facility. Needs and Care plan indicate the R1 is independent with toileting and can ambulate independently. Charting Narrative for R1, indicated that a fall occurred on 09/28/2023, in R1's room,when she was later taken to a medical facility as she expressed pain. Records show that the responsible parties were contacted and a report was sent to the Licensing office as required. Notes also indicate that R1 did not return to the facilty after 09/28/2023. R1 was not available for interview at time of investigation. ***continued on LIC 9099C*** Unsubstantiated Interview with S1 indicates that records show R1 is independent in the category for the risk of falling and the goals will be to avoid injury from falls. The facility interventions are to report any changed in condition to the Physician and follow any orders. Charting narrative does indicate that resident was observed sleeping during night check frequent checks will continue. Based on the information obtained there is not enough evidence that staff did not properly supervise resident resulting resident to fall. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. This report was signed by LPA Prieto and Executive Director Llamas and a copy of this report was left with the facility.the state’s words, verbatim · CDSS document, Jan 20, 2026 · control 56-AS-20231009102802

Type of visit: Case Management - Incident

LPA E. Conchas conducted a health and safety check to the facility on the date noted above in response to a unusual incident reported that occurred at the facility. LPA gathered pertinent documents, interviewed staff and took a tour of the facility. There were no heath and safety concerns observed at the time of LPAs visit and no deficiencies were cited Nothing further.the state’s words, verbatim · CDSS document, Dec 19, 2025

Type of visit: Case Management - Other

On 12/5/2025, LPA E. Conchas made an unannounced visit to deliver amended report on complaint control number: 56-AS-20250806084252 LPA E. Conchas originally delivered the complaint allegation finding on 11/26/2025. LPA met with Executive Director Rachelle Wheaton and was informed of the reason for the visit. Findings for the allegation Residents mattress is not in good/sanitary condition remain as SUBSTANTIATED. Findings for the allegation Staff did not ensure there was a mattress pad on residents’ mattressremain as UNSUBSTANTIATED. An exit interview was conducted where this report and Appeal Rights were discussed and a copy provided to Executive Director Rachelle Wheaton.the state’s words, verbatim · CDSS document, Dec 5, 2025

Type of visit: Case Management - Other

On 12/5/2025, LPA E. Conchas made an unannounced visit to deliver amended report on complaint control number:56-AS-20251001084626 LPA E. Conchas originally delivered the complaint allegation finding on 10/7/2025. LPA met with Executive Director Rachelle Wheaton and was informed of the reason for the visit. Findings for the allegation Staff do not provide adequate supervision resulting in residents engaging in physical altercations due to staff shortageremain as UNSUBSTANTIATED. An exit interview was conducted where this report and Appeal Rights were discussed and a copy provided to Executive Director Rachelle Wheaton.the state’s words, verbatim · CDSS document, Dec 5, 2025

Allegation investigated: Staff neglect resulted in resident death

Licensing Program Analyst (LPA), Yolanda Delgado, arrived unannounced to conclude a complaint investigation into the allegation of staff neglect resulted in resident death. LPA met with Administrator, Rachelle Wheaton and discussed the purpose of the visit. Rachelle had to excuse herself due to a prior engagment, Business Office Manager, Jonathan Guzman met with LPA. Rachelle returned during the discussion of the report. During the investigation, interviews were conducted with facility staff and residents and records were obtained and reviewed. On July 10, 2021, Community Care Licensing received a complaint alleging staff’s neglect resulted in resident’s death. It was reported R1 was at the facility having lunch in the dining room when R1 started choking. Based on the review of the Ambulance Billing Report (ABR) dated July 10, 2021, facility staff called emergency services at 12:08 pm and emergency services personnel arrived at 12:12 pm. The ABR report indicates under Dispatch Information, the “Complaint at Disp:” is listed as choking. Emergency Services Personnel was at patient’s side at 12:14 pm and “immediately began HQ CPR”. (Continued on Page 2) Substantiated (Continued from Page 1) HQ CPR is abbreviated for high-quality cardiopulmonary resuscitation. Fire medical services observed that R1’s passageway was obstructed with food and removed the food with forceps. R1 began to have a pulse. R1 was transported to the hospital for further evaluation and care. Based on hospital records dated July 10, 2021, medical personnel advised R1’s responsible party that R1 was “developing post hypoxic myoclonic epilepsy activity in the setting of approximately 15 minutes downtime without adequate brain oxygenation leading to likely permanent anoxic brain injury”. Hospital records dated July 12, 2021, reveal at 1740 hours, medical personnel were called to R1’s room due to R1 was “without heart rate or breathing. Pupils fixed no spontaneous heart rate no spontaneous breathing time of death 1740 hours cause of death anoxic brain injury from cardiac arrest from choking.” Information obtained from interviews revealed the following: a staff witness revealed they heard R1 coughing and gave R1 a cup of water. R1 continued to cough. The staff indicated R1 was asked if they were okay and R1 responded with their hands in a motion perceived by the staff to indicate that R1 was okay. Due to R1’s continued coughing, the staff called for Med Tech Rita Ortiz. Ortiz responded within 5 minutes, asking R1 if they were okay, to which R1 responded using the same hand motions. Ortiz then instructed the staff to stay with R1 while Ortiz left the area to call 911. It was reported Ortiz did not return to the common lunchroom until emergency services personnel arrived at the facility. Ortiz was interviewed and reported she received a call from another staff. Ortiz responded to the common lunchroom in less than one minute to assess R1. Ortiz reports R1 took a sip of water and motioned with their hands that they were okay. The staff pointed out R1 was gurgling. Ortiz instructed this staff to stay with R1 while she called 911. Ortiz contacted 911 and then started paperwork in preparation for emergency services personnel to arrive. Ortiz reports she did not think R1 was choking because R1 took a sip of water. Ortiz reports she observed R1’s face to change color but R1 was still breathing. Ortiz further reports she did not think R1 required cardiopulmonary resuscitation (CPR) because R1 was breathing and conscious. Ortiz reports that when she called 911, she reported R1 was conscious but was not feeling well. This contradicts the ABR which indicates the call came in as choking. Ortiz reports the 911 operator instructed her to call back if anything changed and to have someone watch R1. Ortiz explained the other staff was already with R1 at the time. The staff who was left to watch R1 was hired on May 20, 2021. The staff reported they had not yet had CPR or first aid training at the time of the incident. (Continued on Page 3) (Continued from Page 2) Death certificate dated September 3, 2021, revealed immediate cause of death is anoxic encephalopathy and obstruction of the airway by food. Interviews confirmed staff did not perform first aid to R1 during the choking incident. R1 exhibited signs such as coughing, turning color and gurgling. R1’s presence in the lunchroom along with the fact they were eating at the time of the incident further indicates first aid was needed. According to mayoclinic.org, choking is a life-threatening emergency because it cuts off oxygen to the brain, and therefore, first aid (abdominal thrust) should be performed immediately. The allegation that staff neglect resulted in R1’s death is substantiated. The preponderance of evidence standard has been met. The facility will be cited for violation of California Code of Regulations, Title 22, Division 6, Chapter 8, Sections 87468.2(a)(8) and 87411(a). This poses a health and safety risk to clients in care. A substantiated finding means that the allegation is valid because the preponderance of evidence standard has been met. In addition, this violation posed an immediate Health and Safety risk to resident(s) in care. An Immediate Civil Penalty of $500 is being assessed. The licensee was also informed that a civil penalty may be assessed based on Health and Safety Code § 1569.49. An exit interview was conducted, a copy of this report, along with the 9099-D, Civil Penalties and appeal rights were provided to Administrator Rachelle Wheaton and Business Office Manager Jonathan Guzman.the state’s words, verbatim · CDSS document, Oct 29, 2025 · control 18-AS-20210713153425

From the deficiency page — Deficiency type: Type A · Section cited: HSC 87468.2(a)(8) · Plan of correction due date: Oct 30, 2025

87468.2(a)(8) Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (8) To be free from neglect, financial exploitation, involuntary seclusion, punishment, humiliation, intimidation, and verbal, mental, physical, or sexual abuse. This requirement was not met as evidenced by: Based on interviews and records reviewed staff neglect resulted in R1's death. This poses a potential health, safety, or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Oct 29, 2025

Plan of correction: Licensee will ensure that all care staff/med tech in the care department will be CPR/First Aid training as well as in-services training with all staff. Licensee will email copies of the current care staff CPR/First Aid training with in-service training to LPA by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(a) · Plan of correction due date: Nov 5, 2025

Personnel Requirements: General Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement was not met as evidenced by: based on interviews and records reviewed S1 failed to demonstrate competency when she did not perform first aid. This poses a potential health, safety, or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Oct 29, 2025

Plan of correction: Licensee confirmed S1 is no longer an employee. Licensee will ensure in-service on the requirements and expectation of their duties while on duty, will email copies to LPA by POC due date.

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Javier Prieto arrived to the facility to have Resident Service Director Rashelle Wheaton sign amended Complaint Investigation Report (LIC 9099) #18-AS-20220126121631. Report was signed by LPA Prieto and MS Wheaton and a copy was left with the facility.the state’s words, verbatim · CDSS document, Aug 14, 2025

Allegation investigated: Staff is neglecting residents in care.

Licensed Program Analysts (LPAs), Edith Conchas and Renese Howell-Small conducted an unannounced visit to conclude the investigation and deliver findings to the above-mentioned complaint. LPAs identified themselves and discussed the purpose of the visit to Resident Servcies Director, Rachelle Wheaton. The investigation consisted of LPA observations, interviews with staff and residents, and review of pertinent records. It is alleged that staff are neglecting residents in care. LPA interviewed the reporting party, staff, and residents. Interviews revealed that Resident 1 (R1) and Resident 2 (R2) were in a physical altercation. On 4/25/2025 Staff 1 (S1) observed R2 kicking R1 in the hallway. Interviews with staff revealed that although R1 was bloodied, emergency services were not contacted. Therefore, this allegation is SUBSTANTIATED. A deficiency will be cited. Substantiated A SUBSTANTIATED finding means that the allegation is valid because the preponderance of the evidence standard has been met. An exit interview was conducted where this report, LIC9099, LIC9099-C, LIC9099-D and Appeal Rights were discussed and a copy provided to Resident Services Director, Rachelle Wheaton.the state’s words, verbatim · CDSS document, Aug 8, 2025 · control 56-AS-20250618132605

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Aug 11, 2025

87468.2(a)(4) Additional perosnal rigths of residents of privately operated faclilites (a)... facilities for the elderly shall have all of the following personal rights: (4) to care, supervision and services that meet...This requirement is not met as evidence by: Based on interviews and records review licensee did not ensure the physical safety of resident 1 (R1) and did not call 911 per the family's request, which posed an immediate risk to the health and safety of the resident in care.the state’s words, verbatim · CDSS document, Aug 8, 2025

Plan of correction: licensee/Adminsitrator will complete an in house training on emergency protocol when residents are in need of immediate care and submit proof to LPA by plan of correction due date.

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.

Allegation investigated: Staff not keeping facility free of pests. Staff mismanaging resident’s medication.

Licensing Program Analyst (LPA) Sarina Ramirez conducted an unannounced visit to the facility to deliver findings on a complaint investigation regarding the above allegations. LPA met with Executive Director Heidi Charette and discussed the purpose of the visit. Regarding allegation #1, LPA conducted a walk through of the facility and toured the kitchen, LPA did not observe pests. LPA obtained pertinent documentation corroborating facility does not have a pests problem. LPA conducted seven (7) resident interviews, 6 of the 7 residents confirmed the facility does not have a pests problem. 1 of the 7 residents stated they seen pests along the baseboards of the dining room, but could not give a timeframe when they were observed. LPA conducted seven (7) staff interviews, all whom confirmed the facility does not have a pests problem. Unsubstantiated Based on the evidence gathered during the investigation, the above allegation is Substantiated. A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. An exit interview was conducted where this report (LIC 9099), LIC 9099D was discussed, and a copy was provided, along with a copy of the appeal rights to Executive Director Heidi Charette. Regarding allegation #2, LPA randomly audited four (4) residents medication along with their MAR and all medication is punched and documented correctly. LPA conducted 7 resident interviews, all whom confirmed staff have not mismanaged their medication. LPA conducted 7 staff interviews, all whom confirmed staff do not mismanage resident’s medication. Based on LPA's observations, record reviews, and interviews, the above allegations are unsubstantiated. This means that although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. An exit interview was conducted where this report was discussed, and a copy was provided to Executive Director Heidi Charette at the conclusion of the visit.the state’s words, verbatim · CDSS document, Jun 11, 2025 · control 56-AS-20250401130020

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87608(a)(5) · Plan of correction due date: Jun 12, 2025

87608. Postural Supports (a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself...(5)Under no circumstances shall postural supports include tying, depriving, or limiting the use of a resident's hands or feet. Based on interviews, the licensee did not comply with the section cited above evidenced by tying a resident in his wheelchair with a bedsheet which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jun 11, 2025

Plan of correction: Executive Director has provided LPA with the in service training to staff on restraining residents.

Type of visit: Required - 1 Year

Licensing Program Analysts (LPAs) Sarina Ramirez and Eldin Serrano made an unannounced visit to the facility to conduct a required annual inspection. LPAs met with Executive Director Heidi Charette , and discussed the purpose of the visit. The facility is a Residential Care Facility for the Elderly (RCFE) with a license capacity of (75), a current census of (45). LPAs conducted an overall inspection of the facility, which included, but was not limited to, the following: Physical Plant/Environment: Indoor and outdoor passageways are free of obstruction. The facility does not have a swimming pool or similar bodies of water. The facility has sufficient lighting and is maintained at a comfortable temperature. The facility has sufficient indoor and outdoor space for resident activities. The facility is equipped with operating smoke detectors/carbon monoxide alarms, working laundry equipment, and telephone service. Resident’s showers, toilets, and hand washing areas were operating properly. The hot water temperature in four (4) resident cottage bathrooms measured between 106.5 and 116 degrees F. Four (4) resident’s bedrooms had beds, bed linen, chairs, dresser, storage space and sufficient lighting. The facility has sufficient linens, towels, and personal hygiene items for residents. The facility has posted in a common area, facility license, personal rights, menu, activities, facility sketch, emergency disaster plan and telephone numbers, CCLD complaint poster, and Ombudsman poster. Food Service: Facility kitchen and dining area are maintained clean. The facility has sufficient non-perishable and perishable food supply for residents in care. Sharps and chemicals were kept locked and inaccessible to residents in care. Continuation on LIC – 809C: Care & Supervision: Facility has 24-hour/7days a week care staff. Facility staff have current CPR/first aid training. Medical Related Services: Resident’s medications are labeled and centrally stored in a locked medication cart. Six (6) resident medications were audited at random, no deficiencies. Record Review: Five (5) Staff files reviewed were observed to be complete. Six (6) Resident files reviewed were observed to be complete. Last disaster drill was conducted in June 1, 2025. Based on observations and record review no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted, and this report along was discussed and provided to Executive Director Heidi Charette at the conclusion at the visit.the state’s words, verbatim · CDSS document, Jun 4, 2025

Allegation investigated: Facility staff did not know resident's whereabouts for an extended period of time. Resident did not receive assistance after falling for an extended period of time. Resident sustained injuries (sun/heat blisters, head wound) while in care.

Licensing Program Analyst (LPA) Javier Prieto arrived to the facility to conduct a complaint investigation regarding the above allegations. LPA Prieto met with Executive Director Charette and explained the elements of the complaint. Allegation #1 - Interview with Executive Director states the facility is more that sufficiently staffed to meet the needs of the residents in care. LPA interviewed S1, S2 S3 and S4 who stated residents are cared for in groups and specific times so that they are aware of resident's whereabouts at the facility. LPA interviewed residents #1 (R1), R2, R3, R4, R5, R6 and R7 all stating there is sufficient staff who care for their needs and whereabouts. Allegation #2 - LPA Prieto was not able to interview R8, in question, who no longer resides at the facility. Documentation obtained during today's investigation chronicles the timeline of R8's fall on 04/17/2022, with a subsequent call to 911 and transfer to a medical facility. There is no evidence to corroborate the R8 was Unsubstantiated not assisted for a long period of time after the initial fall. Interview with staff #1 (S1), S2, S3 and S4 stated that they are aware of client's whereabouts and can view residents from inside the facility to the outdoor courtyard through the large, unobstructed windows. Allegation #3 - Documentation obtained during today's investigation chronicles the timeline of R8's fall on 04/17/2022, with a subsequent call to 911 and transfer to a medical facility. There is no evidence to corroborate that R8 sustained injuries related (sun/heat blisters, head wound) while in care. Based on the information obtained there is not enough evidence to support the allegations made in this complaint. Therefore, the allegations are deemed UNSUBSTANTIATED at this time. This report was signed LPA Prieto and Executive Director Charette and a copy was left with the facility.the state’s words, verbatim · CDSS document, May 13, 2025 · control 56-AS-20220421150345

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Javier Prieto arrived the facility to conduct additional interviewed and have Executive Director Charette sign amended COMPLAINT CONTROL NUMBER: 56-AS-20220310135429. LPA Prieto and Executive Director Charette signed the amended report and a copy was left at the facility.the state’s words, verbatim · CDSS document, May 13, 2025

Allegation investigated: Resident sustained unexplained injuries while in care. Facility is not following reporting requirements. Facility is not sufficiently staffed to meet the resident's needs. Facility staff is not properly trained.

Licensing Program Analyst (LPA) Becky Mann conducted an unannounced visit to the facility to initiate a complaint investigation. LPA met with Heidi Charette, Administrator and discussed the purpose of the visit. The investigation consisted of LPA pertinent record reviews and interviews with staff and residents. The allegation that Resident sustained unexplained injuries while in care. Staff interviewed stated that they take the precautions to prevent residents from sustaining injuries while in care. Residents interviewed were not able to respond due to cognitive impairment. The Facility is not following reporting requirements. Based on LPAs observations, interviews and record reviews with the current administrator Heidi Charette, the facility does follow reporting requirements. The allegation at the time of the incident there was not enough evidence to corroborate the allegation. Unsubstantiated The allegation that Facility is not sufficiently staffed to meet the resident’s needs. Based on LPA observations, interviews, and records reviews, the facility is sufficiently staff to meet the resident's needs. Interviews with staff stated that the facility is sufficiently staff to meet the resident's needs. Residents interviewed were not able to respond due to cognitive impairment. The allegation that Facility staff is not properly trained. Based on LPA observations, interviews, and record reviews, the facility staff is properly trained. Interviews conducted with facility staff, all staff have received required trainings and certifications to provide proper care for residents. Residents interviewed were not able to respond due to cognitive impairment. Based on evidence obtained during this investigation, the allegations above are Unsubstantiated; meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. An exit interview was conducted where this report was discussed and a copy of this report was provided to the Heidi Charette, Administrator at the conclusion of the visit.the state’s words, verbatim · CDSS document, Mar 5, 2025 · control 18-AS-20210518090908

Allegation investigated: Resident developed a pressure injury while in care. Staff do not ensure resident care needs are being met.

Licensing Program Analyst (LPA) Paola Guerrero conducted an unannounced visit to deliver findings on the allegations listed above. LPA met with Facility Business Office Manager (BOM), Jonathan Guzman, and explained the purpose of the visit. The investigation consisted of interviews and review of records. First allegation: Resident developed a pressure injury while in care. Regarding the allegation stated above LPA conducted a record LPA discovered that R#1 was being treated for stage #2 pressure injury along with elbow skin tear by Inland Valley Hospice. LPA review medication record and discovered that cream was prescribed to R#1 to help treat R#1 affected areas. LPA conducted interview with S#1 who informed LPA that R#1 was being treated for pressure injury according to resident treatment plan. Second allegation: Staff do not ensure resident care needs are being met. Regarding the allegation stated above LPA conducted a review of R#1 records and discovered that Resident #1 was bedbound and required to be repositioned every two hours based on R#1 care needs. Unsubstantiated LPA conducted an interview with S#1 who informed LPA that R#1 was being repositioned 2-hours and facility staff was following hospice treatment according to R#1 treatment plan. S#1 informed LPA about being present when R#1 was being repositioned. LPA conducted interviews with S#2, S#3, and S#4 who informed LPA that staff support has been consistent. S#3, and S#4, informed LPA that facility does a good job on hiring staff, and that they have not witness facility being low on staffing support. LPA conducted interviews with R#2, R#3, and R#4, all residents informed LPA that they have lived at the facility for over two years and have no concerns regarding their care. R#2, R#3, and R#4, informed LPA that facility has enough caregivers that help meet resident care needs every day. Based on corroborating evidence obtained during the course of the investigation, LPA has determined that the above allegation is Unsubstantiated. Unsubstantiated: meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. An exit interview was conducted where this report (LIC 9099) was discussed, and a copy was provided to Facility Business Office Manager Jonathan Guzman at the end of the visit.the state’s words, verbatim · CDSS document, Dec 24, 2024 · control 56-AS-20240523081611

Allegation investigated: Staff did not ensure residents call buttons are working.

Licensing Program Analyst (LPA) Magda Malcore conducted an unannounced visit to the facility to initiate a complaint investigation. LPA met with Heidi Charette, Executive Director and explained the purpose of the visit. Regarding the allegation, staff did not ensure residents call buttons are working, call buttons were inspected at random in separate wings of the facility. The signal system button in room 100 was tested and observed to be non-operational. Based on LPA observations, the allegation is Substantiated. A finding that the complaint is Substantiated means that the allegation(s) is valid because the preponderance of the evidence standard has been met. An exit interview was conducted where reports (LIC9099&LIC9099-D) were discussed and a copy with Appeal Rights was provided at the conclusion of the visit. Substantiatedthe state’s words, verbatim · CDSS document, Jun 5, 2024 · control 56-AS-20240529094451

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Jun 19, 2024

(a) The facility shall be clean, safe, sanitary and in good repair at all times. This requirement is not met as evidence by: The Licensee did not comply with the section cited by the signal system in room 100 was not operating; which poses/posed a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jun 5, 2024

Plan of correction: The Executive Director stated that maintenance staff would check the battery in the call system before the end of the day. The Executive Director stated that the call system button in room 100 is now working properly. The Executive director shall provide a certification statement confirming that the signal system is working properly.

The state marks this report as 3 pages; the online copy we transcribed has 2. You can request the full file from the county licensing office.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Paola Guerrero made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection. LPA met with Facility LVN Delcie Mucha and was granted entry to the facility. The facility is a Residential Care Facility for Elderly (RCFE) Licensed capacity is (75) current census (50). LPA was accompanied by Delcie, to conduct a general overall inspection, which included, but was not limited to, the following: Physical Plant: The facility is operating in the capacity approved by Community Care Licensing (CCL). There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature. LPA inspected resident’s bedrooms; they are equipped with required furniture such as: mattresses, nightstands, storage space, and sufficient lighting; bathrooms were clean, and appliances were operating appropriately. LPA observed sufficient furniture and lighting throughout the facility. The facility is equipped with operating smoke detectors and carbon monoxide alarms. Posters such as personal rights, the CCL complaint poster, and the disaster plan were posted in a common area. Cleaning supplies, toxins, sharps, and other dangerous items were kept inaccessible to residents in care. There was a designated storage space for resident/staff files. Medications are kept inside Med-Room inaccessible to residents in care. 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 number of residents in care. Care & Supervision: Facility has sufficient care staff for coverage 24 hours a day, 7 days a week. All staff members working in the facility have criminal record clearance through the department. Record Review: LPA reviewed four (4) resident files for admission agreements, updated physician reports, and needs and services plans. LPA also reviewed four (4) staff files for First Aid/CPR certification, criminal record clearance, training, and health screenings. Medications were audited at random and appeared to be dispensed appropriately by staff members. Based on the observations made 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 (LIC809) was discussed and provided to Facility LVN Delcie Muchathe state’s words, verbatim · CDSS document, May 18, 2024

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Bernadette Allen met with Hedi Charette Administrator at Community Care Licensing Division (CCLD) Adult and Senior Care (ASC) Regional Office 12/14/2023 at 1:50 PM to initiate a Case Management Office Visit. LPA Allen requested that Hedi Charette come to the office to sign an amended complaint investigation control number 56-AS-20221102154307 that was conducted on 2/28/2023. The report was missing an allegation and investigation information. During the investigation it was determined that on 10/29/2022 an incident occurred while S1 was assisting R1 with their shoes when R1 pulled her hair and S1 grabbed R1’s hands and place her fingers into R1’s hand to remove her hair from R1’s hands. On 10/30/2022, interviews revealed there was significant bruising to R1's hands and facility staff did not seek medical attention at the time of observing R1’s bruised hands. It was not until 11/1/2022 that the administrator ordered a mobile imaging technician to come to the facility and to x-ray of R’1’s right hand. Based on interviews, observations, and medical records the facility is being cited for not seeking medical attention in a timely manner. A deficiency is being cited on the attached LIC 9099-D. An exit interview was conducted where this report was discussed, and a copy was provided to Hedi Charette Administrator at the conclusion of the visit with appeal rights.the state’s words, verbatim · CDSS document, Dec 14, 2023

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(1) · Plan of correction due date: Dec 15, 2023

INCIDENTAL MEDICAL & DENTAL CARE The licensee shall arrange, or assist in arranging, for medical & dental care appropriate to the conditions and needs of residents. This requirement is not met as evidenced by: Based on file review & interviews, the licensee failed to seek medical attention in a timely manner it was 2 days before facility staff arranged for appropriate medical care for R1.the state’s words, verbatim · CDSS document, Dec 14, 2023

Plan of correction: The licensee has agreed to provide in-service training on the cited regulation to all staff to ensure medical care is arranged in a timely manner along with a statement of understanding signed by all staff by the POC date of 12/15/2023.