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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 366425610
Report Date: 09/08/2023
Date Signed: 09/08/2023 12:01:38 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
07/25/2023 and conducted by Evaluator Magda Malcore
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20230725152152
FACILITY NAME:EXCELCAREFACILITY NUMBER:
366425610
ADMINISTRATOR:ANDERSON, DORRISFACILITY TYPE:
740
ADDRESS:11400 POPLAR STREETTELEPHONE:
(909) 796-4553
CITY:LOMA LINDASTATE: CAZIP CODE:
92354
CAPACITY:10CENSUS: 8DATE:
09/08/2023
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Dorris Anderson, LicenseeTIME COMPLETED:
11:45 AM
ALLEGATION(S):
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9
Staff speak inappropriately to residents in care
INVESTIGATION FINDINGS:
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13
Licensing Program Analyst (LPA) Magda Malcore conducted an unannounced complaint visit to the facility. LPA met with Dorris Anderson, Licensee and discussed the purpose of the visit. The investigation consisted of LPA observations, pertinent document review, and interviews with relevant parties.

Regarding the allegation, staff speak inappropriately to residents in care, Licensee and staff interviewed deny speaking inappropriately to residents in care. Five (5) out of (7) residents interviewed deny that staff have spoken inappropriately to them, nor have they witnessed staff speak inappropriately to other residents.

Based on information obtained during the investigation, the allegation 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 with where this report was discussed and a copy of this report with appeal rights was provided to the Licensee at the conclusion of the visit.

Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Magda MalcoreTELEPHONE: 951-248-0316
LICENSING EVALUATOR SIGNATURE:

DATE: 09/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2023
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
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
07/25/2023 and conducted by Evaluator Magda Malcore
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20230725152152

FACILITY NAME:EXCELCAREFACILITY NUMBER:
366425610
ADMINISTRATOR:ANDERSON, DORRISFACILITY TYPE:
740
ADDRESS:11400 POPLAR STREETTELEPHONE:
(909) 796-4553
CITY:LOMA LINDASTATE: CAZIP CODE:
92354
CAPACITY:10CENSUS: 8DATE:
09/08/2023
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Dorris Anderson, LicenseeTIME COMPLETED:
11:45 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff are not meeting resident's showering needs
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Magda Malcore conducted an unannounced complaint visit to the facility. LPA met with Dorris Anderson, Licensee and discussed the purpose of the visit.
The investigation consisted of LPA observations, pertinent document review, and interviews with relevant parties.
Regarding the allegation, staff are not meeting resident's showering needs, Licensee and staff interviewed stated that resident 1 (R1) and resident 2 (R2) are too heavy to lift and shower. Licensee stated that both R1 and R2 are obese and staff are hurting their backs trying to transfer the residents out of bed and into the shower. Licensee stated that R1 and R2 are given bed baths everyday but not showers. Outside party interviews reveal that the Licensee was offered a Hoyer lift to assist with resident transfers. Licensee stated that there is not enough room in R1's and R2's bedroom for a Hoyer lift.
Based on information obtained during the investigation, the allegation is Substantiated. A finding of substantiated means that the preponderance of the evidence standard has been met.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Magda MalcoreTELEPHONE: 951-248-0316
LICENSING EVALUATOR SIGNATURE:

DATE: 09/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 56-AS-20230725152152
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: EXCELCARE
FACILITY NUMBER: 366425610
VISIT DATE: 09/08/2023
NARRATIVE
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A deficiency was citied, and a plan of correction was discussed with the Licensee.

An exit interview was conducted and copies of reports LIC9099 and LIC9099-D with appeal rights where provide to the Licensee at the conclusion of the visit.
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Magda MalcoreTELEPHONE: 951-248-0316
LICENSING EVALUATOR SIGNATURE:

DATE: 09/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 56-AS-20230725152152
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: EXCELCARE
FACILITY NUMBER: 366425610
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/08/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/11/2023
Section Cited
CCR
87468.2(a)(4)
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87468.2 Additional Personal Rights...(a)Residents in all residential care facilities... shall have...rights:(4)To care...and services that meet their individual needs.This requirement it not met as evidence by:
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Licensee stated that R1 is leaving the facility today and R2 is no longer at the facility. Licensee shall submit to the licensing agency a statement of understanding on the cited regulation.
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Licensee not providing R1 and R2 with proper showers which poses an immediate health, safety, and personal rights risk to persons in care.
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7
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7
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7
1
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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: Magda MalcoreTELEPHONE: 951-248-0316
LICENSING EVALUATOR SIGNATURE:

DATE: 09/08/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 4