366425610-9-14-2023-56-AS-KCLS-CW5T58-20230929142505

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 366425610
Report Date: 09/14/2023
Date Signed: 09/14/2023 12:20:07 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
09/11/2023 and conducted by Evaluator Magda Malcore

COMPLAINT CONTROL NUMBER: 56-AS-20230911151218

FACILITY NAME:	EXCELCARE		FACILITY NUMBER:	366425610
ADMINISTRATOR:	ANDERSON, DORRIS		FACILITY TYPE:	740
ADDRESS:	11400 POPLAR STREET		TELEPHONE:	(909) 796-4553
CITY:	LOMA LINDA	STATE: CA	ZIP CODE:	92354
CAPACITY:	10	CENSUS: 8	DATE:	09/14/2023
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Dorris Anderson, Licensee		TIME COMPLETED:	12:15 PM

ALLEGATION(S):

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Staff left resident unattended for extended periods

INVESTIGATION FINDINGS:

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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.
Regarding the allegation, staff left resident unattended for extended periods, Administrator and (4) staff interviews deny leaving residents unattended for extended periods. Four (4) staff and (7) resident interviews reveal that the after returning from the Innovage program, the Innovage driver brings residents directly inside the facility. In addition, seven (7) resident interviews reveal that they have not witnessed residents being left unattended for extended periods.
Based on pertinent record review and interviews with relevant parties, the allegation is Unsubstantiated; a finding of UNSUBSTANTIATED means that although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur.
An exit interview was conducted where this report was discussed and provided with appeal rights to the Licensee at the conclusion of the visit.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Magda Malcore	TELEPHONE: 951-248-0316
LICENSING EVALUATOR SIGNATURE:	DATE: 09/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2023

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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