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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 361880525
Report Date: 05/20/2022
Date Signed: 05/20/2022 02:56:21 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/18/2022 and conducted by Evaluator Bernadette Allen
COMPLAINT CONTROL NUMBER: 56-AS-20220518164927
FACILITY NAME:MERRILL GARDENS AT RANCHO CUCAMONGAFACILITY NUMBER:
361880525
ADMINISTRATOR:TAMO, DAVIDFACILITY TYPE:
740
ADDRESS:9942 HIGHLAND AVENUETELEPHONE:
(909) 303-9545
CITY:RANCHO CUCAMONGASTATE: CAZIP CODE:
91737
CAPACITY:150CENSUS: 113DATE:
05/20/2022
UNANNOUNCEDTIME BEGAN:
09:54 AM
MET WITH:David Tamo Administrator TIME COMPLETED:
03:05 PM
ALLEGATION(S):
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Licensee refused to allow resident to return to the facily after discharge from the hospital.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Bernadette Allen conducted an unannounced visit to the facility to investigate the above allegation. LPA met with licensee David Tamo Administrator.

Based on interview and observations of documents the administrator David Tamo confirmed that (R1) has not been allowed to return to the facility unless 24hr care could be provided upon (R1) return to assist with his higher level of care.

Based on LPA's observations, interviews, and record reviews which were conducted, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6 & Chapter 8), is being cited on the attached LIC9099D. An exit interview was conducted where this report, LIC9099D and appeal rights were provided to Administrator David Tamo.

Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Bernadette AllenTELEPHONE: 951-897-2618
LICENSING EVALUATOR SIGNATURE:

DATE: 05/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2022
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
Citations on this Visit Report are Under Appeal!

Control Number 56-AS-20220518164927
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: MERRILL GARDENS AT RANCHO CUCAMONGA
FACILITY NUMBER: 361880525
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/20/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Under Appeal
Type B
05/20/2022
Section Cited
CCR
87224(a)
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Eviction Procedures-The licensee may evict a resident for one or more of the reasons listed in Section 87224(a) (1) through (5). Thirty (30) days written notice to the resident is required except as otherwise specified in paragraph 5.This requirement is not met as evidenced by:
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Licensee has agreed to review Title 22, Section 87224(a) (1 through 5) and write a self certification that the regulation has been read and is understood. Proof of correction due to the Department by 5/23/2022.
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The licensee refused to allow the resident back into the facily after being discharged from the hospital unless 24 hour care is provided. The licenssee did not do a reassesment, or provide R1with a 30day eviction notice.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Bernadette AllenTELEPHONE: 951-897-2618
LICENSING EVALUATOR SIGNATURE:

DATE: 12/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2