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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 361881134
Report Date: 11/05/2024
Date Signed: 10/02/2025 01:47:25 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO ASC, 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
09/18/2024 and conducted by Evaluator Lavette Farlow
COMPLAINT CONTROL NUMBER: 56-AS-20240918154011
FACILITY NAME:ALLARA SENIOR LIVINGFACILITY NUMBER:
361881134
ADMINISTRATOR:HEFNER, LEEANNFACILITY TYPE:
740
ADDRESS:9417 19TH STREETTELEPHONE:
(909) 736-1900
CITY:RANCHO CUCAMONGASTATE: CAZIP CODE:
91701
CAPACITY:120CENSUS: 106DATE:
11/05/2024
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Interim Administrator Ted BurgessTIME COMPLETED:
06:40 PM
ALLEGATION(S):
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Staff did not follow residents DNR
INVESTIGATION FINDINGS:
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Licensed Program Analysts (LPA) Lavette Farlow, conducted an unannounced visit to the facility to conclude an investigation and deliver findings. LPA was granted entrance into the facility by staff. LPA identified self to staff and discussed the purpose of the visit. LPA was escorted to private dinning room where I was introduce to the Interim Administration Ted Burgess and discussed the purpose of the visit.

During today's visit LPA conducted interviews with staff, reviewed and obtained documents and did a walk-through of the facility.

First allegation, It is alleged that staff did not follow resident DNR orders (Do Not Resuscitate). Interviews with staff, witnesses, and upon reviewing of residents facility file revealed that R1 did have a DNR order at time of death dated 12/22/2023. It was also, revealed that staff did attempt CPR and to resuscitate resident in care.

Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Lavette Farlow
LICENSING EVALUATOR SIGNATURE:

DATE: 10/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2025
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 4
Control Number 56-AS-20240918154011
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: ALLARA SENIOR LIVING
FACILITY NUMBER: 361881134
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/05/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/19/2024
Section Cited
CCR
1569.73(c)(2)
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1569.73(c)A facility that has obtained a hospice waiver.. department...call emergency response services at the time of a life-threatening emergency... (2) The resident has.. advance directive, ...Section 4605 of the Probate Code, requesting to forego resuscitative measures.this was not met by..
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Facility will certify on LIC 9098 that Administrator and staff have reviewed and understand regulation section1569.73 (c)(2). Also, implement other measure to notify staff who has a DNR.
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Licensee did not comply with the section cited above by not ensuring staff were aware of residents in care DNR orders for R1 which resulted in staff taking resuscitation measure which poses a potential health, safety and personal rights risk to residents in care.
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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.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Lavette Farlow
LICENSING EVALUATOR SIGNATURE:

DATE: 10/02/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 56-AS-20240918154011
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: ALLARA SENIOR LIVING
FACILITY NUMBER: 361881134
VISIT DATE: 11/05/2024
NARRATIVE
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Based upon investigation findings, the allegation is found to be substantiated.
Substantiated. A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Title 22 regulations, Citation issued on the attached LIC 9099D in accordance with Title 22, Div 6, Chap 8.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Lavette Farlow
LICENSING EVALUATOR SIGNATURE:

DATE: 10/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO ASC, 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
09/18/2024 and conducted by Evaluator Lavette Farlow
COMPLAINT CONTROL NUMBER: 56-AS-20240918154011

FACILITY NAME:ALLARA SENIOR LIVINGFACILITY NUMBER:
361881134
ADMINISTRATOR:HEFNER, LEEANNFACILITY TYPE:
740
ADDRESS:9417 19TH STREETTELEPHONE:
(909) 736-1900
CITY:RANCHO CUCAMONGASTATE: CAZIP CODE:
91701
CAPACITY:120CENSUS: 106DATE:
11/05/2024
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Interim Administrator Ted BurgessTIME COMPLETED:
06:40 PM
ALLEGATION(S):
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Staff did not contact hospice prior to calling 911
Staff did not inform resident's authorized person of their death
INVESTIGATION FINDINGS:
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Allegation #2: Staff did not contact hospice prior to calling 911. Interview with RP, staff, hospice program and file review, did not revealed the order of calls to either agency. The investigation did not reveal any corroborating information that supported the allegation of the order of the calls. This allegation is unsubstantiated.

Allegation #3: Staff did not inform resident's authorized person of their death. Interview of staff, W2, RP, and file review, it was revealed that authorized party was notified. The investigation did not reveal any corroborating information that supported the allegation.
This allegation are unsubstantiated.

A finding that the complaint is UNSUBSTANTIATED means 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, therefore the allegation is unsubstantiated at this time.

One deficiencies were cited during this visit. An exit interview was conducted where this report was discussed with and a copy was provided to the Interim Administrator Ted Burgess.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Lavette Farlow
LICENSING EVALUATOR SIGNATURE:

DATE: 10/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 4