361880525-9-13-2023-56-AS-EMAN-CVWMMK-20230922094402

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 361880525
Report Date: 09/13/2023
Date Signed: 09/13/2023 12:23:24 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
09/06/2023 and conducted by Evaluator Mary Rico

PUBLIC

COMPLAINT CONTROL NUMBER: 56-AS-20230906094211

FACILITY NAME:	MERRILL GARDENS AT RANCHO CUCAMONGA		FACILITY NUMBER:	361880525
ADMINISTRATOR:	TAMO, DAVID		FACILITY TYPE:	740
ADDRESS:	9942 HIGHLAND AVENUE		TELEPHONE:	(909) 303-9545
CITY:	RANCHO CUCAMONGA	STATE: CA	ZIP CODE:	91737
CAPACITY:	150	CENSUS: 105	DATE:	09/13/2023
		UNANNOUNCED	TIME BEGAN:	09:04 AM
MET WITH:	Administrator Usman Chaudary		TIME COMPLETED:	12:27 PM

ALLEGATION(S):

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Facility is unsanitary
Residents are not provided proper assistance by facility staff
Residents in care are not provided proper bedding

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Mary Rico conducted an unannounced visit to deliver findings on the allegations listed above. LPA met with Administrator Usman Chaudary and explained the purpose of the visit. The investigation consisted of staff interviews, resident interviews, document reviews, and facility tour.

For allegation, Facility is unsanitary.

During interview with Administrator, Administrator informed LPA facility has five (5) Housekeeping/Universal workers that provide cleaning services for the facility. During interviews with staff, staff stated they have not witness facility unsanitary. S1 and S2 stated they have assigned rooms where the provide cleaning services for residents. S3 informed LPA they have certain task they must complete to keep facility sanitary.

During interviews with residents, the residents stated they have not witnessed the facility being unsanitary.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 248-0337
LICENSING EVALUATOR NAME: Mary Rico	TELEPHONE: (951) 248-0293
LICENSING EVALUATOR SIGNATURE:	DATE: 09/13/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 56-AS-20230906094211

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: MERRILL GARDENS AT RANCHO CUCAMONGA	FACILITY NUMBER: 361880525
	VISIT DATE: 09/13/2023

NARRATIVE

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During document review, LPA discovered facility has enough staff to provide cleaning services for the facility. LPA reviewed housekeeping task. Administrator provided the following documents: housekeeping schedule, LIC 9020A, LIC 500, Resident’s Admission Agreement, Memory and Assisting Living Schedule. During facility tour, LPA observed Memory and Assisting Living building sanitary.

For allegation, Residents are not provided proper assistance by facility staff.

During interview with Administrator, Administrator stated they have two (2) care givers in Memory and two (2) care givers Assisted Living who provide proper assistance to residents.During interviews with staff, staff informed LPA they provide proper assistance to residents. S3 and S4 informed LPA they provide proper assistances with resident’s ADLs. Staff members stated they have not witness facility staff not providing proper assistance.

During facility tour, LPA observed facility staff providing proper assistance.

For allegation, Residents in care are not provided proper bedding.

During interview with Administrator, Administrator stated residents provide their own bedding. Administrator informed LPA residents who are independent prefer to make their own bed and residents who need assistance are require helped by staff. During interviews with staff, staff stated residents provide their own bedding. S1 informed LPA residents have extra beddings, where they can be replaced when an accident occurs. S3 and S4 stated they assistance residents with their bedding. During facility tour, LPA observed proper bedding for residents and extra beddings for residents in care.

Based on the evidence found during the investigation, the three (3) allegations listed above are deemed UNSUBSTANTIATED. A finding that the complaints are UNSUBSTANTIATED means although the allegation 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 was discussed and provided to Administrator Usman Chaudary, along with a copy of the appeal rights.

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 248-0337
LICENSING EVALUATOR NAME: Mary Rico	TELEPHONE: (951) 248-0293
LICENSING EVALUATOR SIGNATURE:	DATE: 09/13/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2023

LIC9099 (FAS) - (06/04)

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