366412117-5-5-2026-56-AS-NBRN-DTVQZE-20260508123636

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 366412117
Report Date: 05/05/2026
Date Signed: 05/05/2026 10:22:02 AM

Unsubstantiated

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
08/07/2024 and conducted by Evaluator Becky Mann

COMPLAINT CONTROL NUMBER: 56-AS-20240807122804

FACILITY NAME:	CAREGIVERS II		FACILITY NUMBER:	366412117
ADMINISTRATOR:	JAEWON KIM		FACILITY TYPE:	740
ADDRESS:	10945 TRENMAR LANE		TELEPHONE:	(909) 877-0850
CITY:	BLOOMINGTON	STATE: CA	ZIP CODE:	92316
CAPACITY:	0	CENSUS: 0	DATE:	05/05/2026
		ANNOUNCED	TIME BEGAN:	09:50 AM
MET WITH:	Jaewon Hong, Administrator		TIME COMPLETED:	10:30 AM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Questionable death
Facility staff did not assist resident with incontinence care as needed
Facility staff did not follow hospice care plan
Facility staff handled resident in a rough manner
Facility staff stole resident's personal items
Facility staff did not ensure resident had enough to eat

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

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 findings.

On 08/07/2024, the Department received a complaint with multiple allegations including allegations of Questionable Death. The Department investigation consisted of review of facility and medical records, observations, and interviews with pertinent individuals. Resident #1 (R1) cause of death was Methicillin-Resistant Staphylococcus Aureus (MRSA) Bacteremia. A Kaiser Infectious Disease Specialist who treated R1 said that it cannot be conclusively determined that the bacteria entered R1’s bloodstream through wounds. There are other ways the bacterium could have entered R1 system. In addition, R1’s immune system was severely compromised. This impacted R1 ability to fight off any infections. R1 developed sepsis and died in the hospital on 07/29/2024.

Unsubstantiated

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 2

Control Number 56-AS-20240807122804

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

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

The allegation that Facility staff did not assist resident with incontinence care as needed. Based on LPA observations and record reviews, Resident #1 (R1) adult briefs were changed every few hours or as needed. Staff #1 (S1) stated that R1 had frequent bowel movements and was changed 8 to 10 times daily. S1 stated that they always clean and dry R1 during adult brief changes.

The allegation that Facility staff did not follow hospice care plan. Staff #1 (S1) stated that they did everything the hospice nurse told them to do for R1 diaper changes. This included applying cream to the skin. S1 said that they would always clean and dry R1 during diaper changes.

The allegation that Facility staff handled resident in a rough manner. LPA was unable to interview Resident #1 (R1); the resident died on 07/29/2024. LPA interviewed staff, and staff denied handling the resident roughly. LPA was unable to interview other residents in care due to the facility closing on 04/30/2025. There was no evidence to corroborate the allegation.

The allegation that Facility staff stole resident's personal items. LPA was unable to interview Resident #1 (R1); the resident died on 07/29/2024. LPA interviewed staff, and staff denied stealing resident personal items. LPA was unable to interview other residents in care due to the facility closing on 04/30/2025. There was no evidence to corroborate the allegation.

The allegation that Facility staff did not ensure resident had enough to eat. LPA was unable to interview Resident #1 (R1); the resident died on 07/29/2024. LPA interviewed staff, and staff denied not ensuring resident with enough food to eat. Staff stated that there was enough food for the residents at the facility. LPA was unable to interview other residents in care due to the facility closing on 04/30/2025. There was no evidence to corroborate the allegation.

Based on evidence obtained during this investigation, the allegation above is 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 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 2