Inspection Reports for Summerfield Memory Care of Redlands

An unannounced complaint investigation was conducted due to an allegation that staff neglect resulted in a resident's death following a choking incident on July 10, 2021.

The investigation substantiated the allegation that staff neglect resulted in the resident's death due to failure to perform first aid during the choking incident. The facility was cited for violations related to resident rights and personnel competency, posing an immediate health and safety risk.

The complaint alleged that staff neglect resulted in a resident's death due to choking. The allegation was substantiated based on interviews, ambulance and hospital records, and staff statements. The resident exhibited signs of choking and distress, but staff failed to perform first aid. An Immediate Civil Penalty of $500 was assessed.

The visit was conducted for case management purposes related to the signing of an amended Complaint Investigation Report (LIC 9099) #18-AS-20220126121631.

The Licensing Program Analyst arrived to have the Resident Services Director sign the amended complaint investigation report. The report was signed by both parties and a copy was left with the facility.

An unannounced complaint investigation was conducted due to an allegation that staff were neglecting residents in care.

The investigation substantiated the allegation that staff neglected residents, specifically that emergency services were not called after a physical altercation between two residents, posing an immediate risk to resident safety.

The complaint was substantiated. The allegation involved staff neglecting residents, specifically failure to respond appropriately to a physical altercation between residents and failure to call emergency services.

The inspection was an unannounced complaint investigation visit triggered by allegations received on 2025-04-01 regarding staff not keeping the facility free of pests, staff mismanaging resident’s medication, and staff restraining a resident.

The investigation found the allegation of staff restraining a resident substantiated, with evidence that a staff member tied a resident in a wheelchair with a bedsheet, which violated regulations. The allegations of pest problems and medication mismanagement were found unsubstantiated based on observations, interviews, and documentation.

The complaint investigation was initiated based on allegations received on 2025-04-01. The allegation that staff restrained a resident was substantiated. The allegations regarding pest problems and medication mismanagement were unsubstantiated.

Licensing Program Analysts conducted an unannounced required annual inspection of the Residential Care Facility for the Elderly to assess compliance with licensing requirements.

The facility was found to be in compliance with all applicable regulations with no deficiencies cited. The physical plant, food service, care and supervision, medical related services, and record reviews were all satisfactory.

The inspection was an unannounced complaint investigation visit triggered by allegations received on 2022-04-21 regarding resident care concerns including unknown resident whereabouts, delayed assistance after a fall, and injuries sustained while in care.

The investigation found no evidence to support the allegations. Interviews with staff and residents indicated sufficient staffing and awareness of resident whereabouts. Documentation showed timely response to a resident fall with no evidence of prolonged neglect or injury related to the complaint. The allegations were deemed unsubstantiated.

The complaint involved allegations that facility staff did not know a resident's whereabouts for an extended period, a resident did not receive assistance after falling for an extended period, and a resident sustained injuries (sun/heat blisters, head wound) while in care. The investigation concluded these allegations were unsubstantiated.

The visit was conducted as a case management and other type of inspection to conduct additional interviews and have the Executive Director sign an amended complaint report related to Complaint Control Number 56-AS-20220310135429.

The Licensing Program Analyst arrived to conduct additional interviews and obtained signatures on an amended complaint report. No specific deficiencies or violations were detailed in the report.

The visit was related to a complaint investigation identified by Complaint Control Number 56-AS-20220310135429. The report documents the signing of an amended complaint report but does not state substantiation status.

The inspection was an unannounced complaint investigation visit triggered by allegations received on 05/18/2021 regarding unexplained injuries to a resident, failure to follow reporting requirements, insufficient staffing, and improper staff training.

The investigation found all allegations to be unsubstantiated. The facility was observed to follow reporting requirements, was sufficiently staffed, and staff were properly trained. Residents interviewed were unable to respond due to cognitive impairment.

The complaint investigation was unsubstantiated, meaning there was not enough evidence to prove the alleged violations occurred.

An unannounced complaint investigation was conducted based on a complaint received on 2024-05-23 alleging that a resident developed a pressure injury while in care and that staff do not ensure resident care needs are being met.

The investigation found that Resident #1 was being treated for a stage 2 pressure injury and was repositioned every two hours according to the treatment plan. Interviews with staff and residents indicated consistent staff support and no concerns regarding care. The allegations were determined to be unsubstantiated due to lack of preponderance of evidence.

Complaint was unsubstantiated. Although the allegation may have been valid, there was not a preponderance of evidence to prove the alleged violation did or did not occur.

The visit was an unannounced required comprehensive annual inspection of the Residential Care Facility for Elderly (RCFE) to assess compliance with licensing regulations.

The facility was found to be operating within its licensed capacity, clean, in good repair, and maintaining safe conditions. No deficiencies were cited during the inspection, and all reviewed resident and staff files were in order.

The visit was a Case Management Office Visit to address an amended complaint investigation related to an incident on 10/29/2022 involving a resident and staff interaction and the facility's failure to seek timely medical attention.

The facility was cited for failing to seek medical attention in a timely manner after a resident sustained significant bruising to their hands. Medical care was delayed by two days before appropriate action was taken.

The complaint investigation was related to an incident on 10/29/2022 where staff failed to seek timely medical attention for a resident who had significant bruising on their hands. The investigation substantiated the allegation of delayed medical care.

An unannounced required annual visit was conducted to inspect the Residential Facility for the Elderly (RCFE) for compliance with licensing requirements.

The facility was found to be clean, in good repair, and operating in safe conditions with no deficiencies cited. Inspections included facility premises, kitchen, client bedrooms, shower rooms, safety equipment, medication storage and administration, staff and client records.

The inspection was conducted as an unannounced complaint investigation regarding an allegation that facility staff handled a resident in a rough manner.

The investigation found no preponderance of evidence to support the allegation that facility staff handled the resident roughly. X-rays showed a right-hand fracture, but the circumstances and timing were not supported by witnesses or documentation. The allegation was determined to be unsubstantiated.

The complaint alleged that facility staff handled Resident #1 roughly, resulting in injuries. The investigation included review of medical records, facility files, reports, and interviews. The allegation was unsubstantiated due to lack of evidence.

Unannounced visit/investigation of a complaint received on 2022-08-08 regarding allegations of non-compliance with bathing and hygiene agreements, unmet resident needs resulting in bed sores, failure to inform POA of medical condition changes, and inadequate nutrition causing weight loss.

After reviewing documents, interviewing staff and residents' responsible parties, and observing records, the allegations were found to be unsubstantiated as there was insufficient evidence to prove the alleged violations occurred.

The complaint investigation was unsubstantiated, meaning although the allegations may have happened or be valid, there was not a preponderance of evidence to prove the alleged violations did or did not occur.

An unannounced visit was conducted to investigate a complaint received on 2022-09-21 regarding multiple allegations including residents' hygiene needs, cleanliness, withholding of personal items, and failure to provide a rate change notice.

Based on interviews with staff and outside parties, observations of the facility, and records reviewed, all six allegations were deemed unsubstantiated as there was insufficient evidence to prove the alleged violations occurred.

The complaint investigation was unsubstantiated. Allegations included unmet hygiene needs, unclean bathrooms, malodorous rooms, withholding of personal items, and failure to provide a rate change notice. Interviews and observations did not support these claims.

The visit was a Case Management - Other type of visit related to complaint number 56-AS-20220921101913, as indicated by the signing of LIC9099 and LIC9099-C forms.

The report documents the signing of complaint-related forms for complaint number 56-AS-20220921101913 on 01/04/2023. No specific findings or deficiencies are detailed in the report.

The visit was related to complaint number 56-AS-20220921101913. No substantiation status or further complaint details are provided.

Licensing Program Analyst Javier Prieto made an unannounced visit to conduct an annual inspection with an emphasis on infection control.

The facility was observed to have proper infection control measures including signage, hand hygiene supplies, cleaning provisions, and PPE use. No deficiencies were cited during the inspection.

The visit was an unannounced complaint investigation conducted in response to allegations received on 2022-03-10 regarding lack of an administrator, overmedication of residents, and insufficient staffing.

The investigation found that the Executive Director has been in position for over three years with a designated substitute, medication administration records showed no discrepancies or overmedication, and the facility was fully staffed with residents and staff confirming adequate care. Therefore, the allegations were deemed unsubstantiated.

The complaint was unsubstantiated based on the investigation findings that refuted the allegations of no administrator, overmedication, and lack of staff.

The inspection was an unannounced complaint investigation visit triggered by an allegation of lack of supervision resulting in a resident sustaining injuries while in care.

The Licensing Program Analyst conducted interviews with staff and the resident, toured the facility, and found no evidence of injuries or lack of care. The facility was clean and free from clutter. The allegation was deemed unsubstantiated due to insufficient evidence.

The complaint investigation was unsubstantiated based on interviews with multiple staff members and the resident, as well as observations made during the visit.

The inspection was an unannounced complaint investigation regarding allegations that residents were not being changed timely, admitted without a physician's report, without a Hoyer lift, without a medication list, not being showered timely, and that the facility was not sufficiently staffed to meet residents' needs.

The investigation found the facility to be clean and free of obstructions, with sufficient staff and proper documentation for residents. There was not enough evidence to substantiate the allegations, and the complaint was deemed unsubstantiated.

The complaint investigation was unsubstantiated due to lack of sufficient evidence to prove the alleged violations occurred.

An unannounced complaint investigation visit was conducted in response to allegations including neglect resulting in death of a resident, inadequate staffing, temperature control issues, uncleared adults working in the facility, and lack of signaling systems in resident rooms.

The investigation found all allegations to be unsubstantiated based on interviews, observations, and records review. The resident's death was attributed to COPD complications with no evidence of neglect. Staffing levels were adequate, temperature was maintained comfortably, all staff were properly cleared, and resident rooms had signaling systems.

The complaint investigation was unsubstantiated. Allegations included neglect resulting in death, inadequate staffing, temperature issues, uncleared adults working, and lack of signaling systems. Evidence did not support these allegations.

The inspection was an unannounced complaint investigation visit triggered by allegations received on 08/24/2020 regarding resident care concerns including residents left in soiled diapers, inadequate personal protective equipment for staff, and residents' clothing not changed daily.

The investigation included interviews and record reviews which found that staff are required to check and change residents' diapers regularly, adequate personal protective equipment is provided and mandatory for staff, and residents' clothing is changed daily or as needed. The allegations were determined to be unsubstantiated due to lack of preponderance of evidence.

The complaint investigation was unsubstantiated. Allegations included residents left in urine and feces-soaked diapers for extended periods, staff not provided adequate personal protective equipment, and residents' clothing not changed daily. Interviews with staff and review of records did not support these allegations.

The inspection was an unannounced complaint investigation visit triggered by allegations including a questionable death and development of pressure injuries while in care.

The investigation found the allegation of questionable death to be unfounded with no evidence of neglect by facility staff. The allegation regarding pressure injuries was unsubstantiated, meaning there was insufficient evidence to prove neglect caused the injuries.

The complaint involved allegations of a questionable death of Resident #1 due to neglect and that the resident developed pressure injuries while in care. The investigation included review of medical records, interviews, and facility file review. The questionable death allegation was found to be unfounded, and the pressure injury allegation was unsubstantiated.