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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 366412117
Report Date: 05/05/2026
Date Signed: 05/05/2026 10:23:06 AM

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
07/19/2024 and conducted by Evaluator Becky Mann
COMPLAINT CONTROL NUMBER: 56-AS-20240719145550
FACILITY NAME:CAREGIVERS IIFACILITY NUMBER:
366412117
ADMINISTRATOR:JAEWON KIMFACILITY TYPE:
740
ADDRESS:10945 TRENMAR LANETELEPHONE:
(909) 877-0850
CITY:BLOOMINGTONSTATE: CAZIP CODE:
92316
CAPACITY:0CENSUS: 0DATE:
05/05/2026
ANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Jaewon Hong, Administrator TIME COMPLETED:
10:30 AM
ALLEGATION(S):
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Due to neglect, resident developed pressure injuries
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Becky Mann met with Jaewon Hong, Administrator at Community Care Licensing Division (CCLD) Adult and Senior Care (ASC) Regional Office on 05/05/2026 to discuss the complaint investigation. The investigation consisted of LPA observations, pertinent record reviews and interviews with staff.

The allegation that due to neglect, resident developed pressure injuries. Based on LPA record reviews, Resident #1 (R1) adult briefs were changed every few hours or as needed. LPA was unable to interview R1, they passed away on 07/29/2024. LPA interviewed staff. Staff #1 (S1) stated that R1 had frequent bowel movements and was changed 8 to 9 times daily. Staff #2 (S2) confirmed that R1 did not have any sores upon arrival at the facility on 07/03/2024. S2 became aware of the first sore on July 13th or July 14th. S2 assisted with changing R1 linen, cleaned the wound and administered medication as prescribed. Hospice began about 07/16/2024 and Stage 1 wound was noted.

Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Becky Mann
LICENSING EVALUATOR SIGNATURE:

DATE: 05/05/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2026
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 3
Control Number 56-AS-20240719145550
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: CAREGIVERS II
FACILITY NUMBER: 366412117
VISIT DATE: 05/05/2026
NARRATIVE
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Based on evidence obtained during this investigation and information obtained during the Departments investigation on complaint 56-AS-20240807122804, R1 develop pressure injuries due to neglect is Substantiated. A determination that the complaint is substantiated means that the allegation is/are valid because the preponderance of the evidence standard has been met. An exit interview was conducted where this report was discussed, and a copy of this report was provided to Jaewon Hong, Administrator at the conclusion of the visit.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Becky Mann
LICENSING EVALUATOR SIGNATURE:

DATE: 05/05/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 56-AS-20240719145550
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: CAREGIVERS II
FACILITY NUMBER: 366412117
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/05/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/05/2026
Section Cited
CCR
87468.2(a)(4)
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87468.2 Additional Personal Rights Residents in Privately Operate Facilities (a) In addition to the rights listed...(4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient...
This requirement was not met as evidenced by:
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Due to facility closure, there is no Plan of Correction (POC)
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Based on record reviews, observations, and interviews with pertinent individuals, licensee did not comply to ensure R1 was provided with care, supervision, and services required. As a result, R1 sustained pressure injuries while at facility. This violation posed an immediate health and safety 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: Becky Mann
LICENSING EVALUATOR SIGNATURE:

DATE: 05/05/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 3