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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 361800198
Report Date: 12/16/2024
Date Signed: 12/16/2024 01:55:46 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/13/2024 and conducted by Evaluator Paola Guerrero
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20241213134701
FACILITY NAME:MGB CARMEL MANORFACILITY NUMBER:
361800198
ADMINISTRATOR:BERNAL, GLENNFACILITY TYPE:
740
ADDRESS:457 WEST 13TH STREETTELEPHONE:
(909) 982-4786
CITY:UPLANDSTATE: CAZIP CODE:
91786
CAPACITY:6CENSUS: 6DATE:
12/16/2024
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Gloria Hughes- CaregiverTIME COMPLETED:
02:10 PM
ALLEGATION(S):
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9
Staff hit resident.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Paola Guerrero conducted an unannounced visit to deliver findings on the allegations listed above. LPA met with Facility Caregiver Gloria Hughes and explained the purpose of the visit. The investigation consisted of interviews,and observation.

First allegation: Staff hit resident. Regarding the first allegation “Staff hit resident” LPA conducted interviews with Resident #1, #2, and #3, and all informed LPA that they have not been hit or mistreated by staff. In addition, R#2 and R#3 informed LPA that they have not witnessed staff hit or mistreat Resident #1. LPA interviewed Staff #1 and Staff #2 regarding the allegation above both S#1 and S#2 denied hitting or mistreating residents. In addition, S#1, and S#2, informed LPA that they have not witnessed other staff hit or mistreat residents in care. Based on corroborating evidence obtained during the course of the investigation, LPA has determined that the above allegation is Unsubstantiated.

Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Paola GuerreroTELEPHONE: (951) 473-7024
LICENSING EVALUATOR SIGNATURE:

DATE: 12/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 56-AS-20241213134701
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: MGB CARMEL MANOR
FACILITY NUMBER: 361800198
VISIT DATE: 12/16/2024
NARRATIVE
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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 Caregiver Gloria Hughes at the end of the visit.
SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Paola GuerreroTELEPHONE: (951) 473-7024
LICENSING EVALUATOR SIGNATURE:

DATE: 12/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2