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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 366425610
Report Date: 02/20/2025
Date Signed: 02/20/2025 01:43:44 PM

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
11/22/2024 and conducted by Evaluator Sarina Ramirez
COMPLAINT CONTROL NUMBER: 56-AS-20241122101015
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: 9DATE:
02/20/2025
UNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Administrator Dorris Anderson TIME COMPLETED:
01:50 PM
ALLEGATION(S):
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Staff is not ensuring that resident is being fed an adequate amount of food portions.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Sarina Ramirez conducted an unannounced visit to deliver findings on the allegation listed above. LPA met with Administrator Dorris Anderson and explained the purpose of the visit.

Regarding allegation staff is not ensuring that resident is being fed an adequate amount of food portions. LPA Ramirez conducted 6 resident interviews. 4 out of 6 residents informed LPA they are being fed adequate food portions and if they wish to have more food they could ask for more. 2 out of 6 residents informed LPA their food portions are often small.

LPA conducted 4 staff interviews. 4 out of 4 staff informed LPA every resident is different regarding food portions, some eat more than others. However there's enough food for seconds and always remind residents they can ask for more.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Sarina Ramirez
LICENSING EVALUATOR SIGNATURE:

DATE: 02/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/20/2025
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 5
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
11/22/2024 and conducted by Evaluator Sarina Ramirez
COMPLAINT CONTROL NUMBER: 56-AS-20241122101015

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: 9DATE:
02/20/2025
UNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Administrator Dorris Anderson TIME COMPLETED:
01:50 PM
ALLEGATION(S):
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Staff confiscated resident's cable box.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Sarina Ramirez conducted an unannounced visit to deliver findings on the allegation listed above. LPA met with Administrator Dorris Anderson and explained the purpose of the visit.

Regarding Allegaion staff confiscated resident's cable box, LPA interviewed (R1) who stated once R1 notified Administartor they were unable to pay rent, Administrator gave R1 an eviction letter on 11/10/24 and removed the cable box from their room. LPA interviewed Administrator, who stated they provided the TV and cable box to R1, and since R1 is not paying rent Administrator removed the cable box from R1's room. Administrator informed LPA the residents who have cable boxes in their rooms, pay an extra fee every month.

LPA reviewed facilities Admission Agreements and observed that no mentioned of an extra cable box charge is listed in the agreement, however Administrator provided documentation of the residents who pay the extra charge for a cable box.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Sarina Ramirez
LICENSING EVALUATOR SIGNATURE:

DATE: 02/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/20/2025
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 5
Citations on this Visit Report are Under Appeal!

Control Number 56-AS-20241122101015
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: EXCELCARE
FACILITY NUMBER: 366425610
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/20/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Under Appeal
Type B
02/28/2025
Section Cited
CCR
87468.1
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87468.1 Personal Rights of Residents in All Facilities. (a)Residents in all residential care facilities for the elderly shall have all of the following personal rights:...(3)To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature, such as withholding residents’ money or interfering with daily living functions such as eating, sleeping, or elimination. This requirement is not met as evidence by
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Licensee has agreed to read over the "Personal Rights of Residents in All Facilities" regulation and provide training to all staff regarding the violation of resident’s rights. Licensee will email LPA a copy of the training signed and dated by all staff by POC due date.
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Based on interviews, the licensee did not follow Personal Rights regulation for 1 out of 9 residents which, poses a potential Health, Safety, or Personal Rights risk to persons 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: Karen Clemons
LICENSING EVALUATOR NAME: Sarina Ramirez
LICENSING EVALUATOR SIGNATURE:

DATE: 02/20/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/20/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 56-AS-20241122101015
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: EXCELCARE
FACILITY NUMBER: 366425610
VISIT DATE: 02/20/2025
NARRATIVE
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LPA interviewed 3 staff, and 3 out of 3 staff informed LPA, Administrator removed R1's cable box because from their understanding R1 is not paying for the cable service, not paying rent, and the cable box belongs to Administrator.

Based on the evidence gathered during the investigation, the above allegation is 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 87468.1 (3) from Personal Rights Division 6
Chapter 8 Article 08, is being cited on the attached LIC 9099 D.

An exit interview was conducted where this report was discussed, along with LIC 9099D and a copy with appeal rights was provided to Administrator Dorris Anderson at the conclusion of the visit.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Sarina Ramirez
LICENSING EVALUATOR SIGNATURE:

DATE: 02/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/20/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 56-AS-20241122101015
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: EXCELCARE
FACILITY NUMBER: 366425610
VISIT DATE: 02/20/2025
NARRATIVE
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Based on LPAs observations and interviews, the above 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 where this report was discussed and a copy was provided to Administrator Dorris Anderson at the conclusion of the visit.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Sarina Ramirez
LICENSING EVALUATOR SIGNATURE:

DATE: 02/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/20/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5