Complaint Investigation Report

361880724-5-21-2026-56-AS-KCLS-DWEN9Y-20260728101643

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

SAN BERNARDINO ASC , 1650 SPRUCE ST STE 200 MS29-27

This is an official report of an unannounced visit/investigation of a complaint received in our office on

03/19/2026 and conducted by Evaluator Sarina Ramirez

COMPLAINT CONTROL NUMBER: 56-AS-20260319083310

Staff did not answer residents calls for assistance timely

Staff did not intervene when resident hit another resident

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 Caregiver Rose Penilla and discussed the purpose of the visit.

Regarding Allegation #1, that staff did not answer residents’ calls for assistance in a timely manner, LPA was unable to interview Staff #1 (S1) as they are no longer employed at the facility. However, interviews with current staff and the Administrator indicate that staff respond to residents’ calls for assistance in a timely manner.

Regarding Allegation #2, that staff did not intervene when one resident struck another, interviews with staff and outside parties revealed that Staff #1 (S1) was also struck by Resident #2 (R2) while attempting to intervene in the altercation between R1 and R2. Additional staff interviews confirmed that when an altercation is observed, it is staff’s duty to intervene

Based on LPAs observations, record review, and interviews, the above allegations are Unsubstantiated; meaning that although the allegations 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 Caregiver Rose Penilla at the conclusion of the visit.